Bakgrund: I Sverige insjuknar årligen 43 barn av 100000 i typ 1-diabetes (T1DM). Hos barn, som befinner sig i ett stadium av intellektuell och psykologisk utveckling, kan det finnas svårigheter att tillämpa den ideala terapeutiska behandlingen. Denna aspekt är något som särskilt måste beaktas av sjuksköterskan. De komplikationer som kan uppstå vid obehandlad diabetes skapar lidande för både individen, familjen och samhället. Syfte: Beskriva vilka erfarenheter barn i åldern 6-18 år har av att leva med diabetes mellitus typ 1 samt beskriva vilka datainsamlingsmetoder som använts i de utvalda vetenskapliga artiklarna. Metod: En deskriptiv litteraturstudie. Tema, kategorier och datainsamlingsmetoder har identifierats i elva kvalitativa artiklar och sammanställts. Huvudresultat: I samtliga artiklar som redovisas i resultatet framträdde ett tydligt tema – erfarenheten att vara annorlunda. Erfarenheter av att lära sig hantera egenvård i vardagen gestaltades av barn som utmanande. Barns erfarenheter i relation till vården beskrevs som opersonliga. Utifrån den metodologiska frågeställningen framkom det att majoriteten av de inkluderade studierna använde intervjuer som datainsamlingsmetod. Slutsats: Barn i 6-18 årsåldern inhämtade snarlika erfarenheter av att leva med T1DM. Temat ”same same but different” var tydligt övergripande i artiklarna och avspeglar barnens erfarenheter att uppfatta sig “annorlunda” mot andra, från omgivningen eller bara i sitt eget sinne. Upplevelsen att vara “annorlunda” satte sin prägel på sociala- och vårdrelationer och äventyrade hantering av egenvård. Sjuksköterskan bör förankra sitt vårdande arbete till barns unika erfarenheter av att leva med sjukdomen och skräddarsy en vårdstrategi utifrån det individuella barnet. / Background: Annually in Sweden, 43 children out of 100,000 are affected by type 1 diabetes (T1DM). Children, who are in a state of intellectual and psychological development, can have difficulties to apply the ideal therapeutic treatment. This aspect must be given particular consideration by the nurse. The complications that occur due to untreated diabetes, cause suffering for the individual, their family and the society. Purpose: Describe what experiences children in the age of 6-18 years have of living with diabetes mellitus type 1 as well as describe what methods of data collection have been used in the included articles. Method: A descriptive literature study. Theme, categories and data collection methods have been identified in eleven qualitative articles and compiled.   Main result: In all the articles presented in the result a clear theme appeared – the experience of being different. Experiences of learning how to manage self-care in the daily life were by the children described as challenging. Children's experiences in relation to the care were described as impersonal. Based on the methodological issue, it emerged that most of the included studies used interviews for their data collection. Conclusion: Children in the age of 6-18 years gathered similar experiences of living with T1DM. The theme "same same but different" was general in the articles and reflect the children's experiences of being perceived as "different" to others, from the environment or only in their own mind. The experience of being "different" put its stamp on the social and health relationships and jeopardized the management of self-care. The nurse should anchor their caring work to children’s unique experiences of living with the disease and tailor a treatment strategy based on the children’s individual needs.

Background: The prevalence of immunological disorders such as type 1 diabetes (T1D) is increasingly common amongst children, adolescents and young adults. There is also an increase in psychosomatic symptoms (depression, insomnia, anxiety, headaches and fatigue etc.) as well as a decrease in physical activity amongst young people, affecting the well-being and overall health of our younger population. It is therefore important to study the effects of psychological and physical stressors on the immune system, to evaluate their impact on juvenile health. Aim: This thesis explores the impact of psychological and physical stressors on the cellular immune system with special focus on diabetes-related immunity in a young population, using an interdisciplinary approach. Method: When exploring the impact of psychological and physical stressors such as psychological stress due to exposure to psychological stressful experiences or degree of physical activity/training on the cellular immune system in children, adolescents and young women, peripheral blood mononuclear cells (PBMC) were stimulated with antigens (tetanus toxoid (TT) and β-lactoglobulin (βLG)) as well as diabetes-related autoantigens (insulin, heat shock protein 60 (HSP60), tyrosine phosphatase-2 (IA-2) and glutamic acid decarboxylase 65 (GAD65)) and secreted cytokines and chemokines were measured by multiplex fluorochrome technique (Luminex). Populations of Thelper (Th) cells (CD4+), T-cytotoxic (Tc) cells (CD8+), B cells (CD19+), Natural Killer (NK) cells (CD56+CD16+) as well as regulatory T (Treg) cells (CD4+CD25+FoxP3+CD127-), and their expression of CD39 and CD45RA were studied by flow cytometry. Diabetes-related parameters (glucose, C-peptide,proinsulin, pancreatic polypeptide and peptide YY) were measured to studyβ-cell activity and appetite regulation and cortisol was used as a biological marker for psychological and physical stress. Results: Children in families exposed to psychological stress showed an imbalanced cellular immune response as well as an increased immune response towards diabetes-related autoantigens. Also, previous exposure to psychological stress as well as current exposure to psychological stress in young women showed an increased immune response towards diabetes-related autoantigens. Further, previous exposure to psychological stress in young women showed increased numbers of circulating CD56+CD16+ NK cells as wellas decreased numbers of circulating CD4+CD25+FoxP3+CD127- Treg cells. High physical activity in children showed decreased spontaneous immune response as well as a decreased immune response towards diabetes-related autoantigens, while low physical activity in children showed an increased immune response towards diabetes-related autoantigens. Further, endurance training in adolescents, especially in adolescent males and young adolescents, showed an increased immune response towards the diabetes-related autoantigen IA-2. Conclusion: It is evident that psychological and physical stressors such as exposure to psychological stress and degree of physical activity/training impact the cellular immune system. Experiences associated with psychological stress seem to have a negative effect on the cellular immune system in a young population, causing an imbalance in the immune system that could possibly induce diabetes-related immunity. High physical activity in children seems to have a protective effect against diabetes-related immunity. In contrast, low physical activity in children and endurance training in adolescents seems to induce diabetes-related immunity. It is very likely that psychological stressful experiences, low physical activity and intense training such as endurance training all play important roles in the immunological process leading to the development of type 1 diabetes.

År 2012 avled 1.5 miljoner människor till följd av diabetes och förekomsten av sjukdomen ökar i världen hela tiden. Diabetes typ 1 betraktas som den allvarligaste formen av diabetes och varje år insjuknar 400 personer i åldrarna 15–34. Individen måste själv hantera 95% av sin egen diabetesvård vilket gör att hen ställs inför många krav att utföra olika former av livsstilsförändringar. Syftet med studien var att belysa unga vuxnas upplevelser av att leva med diabetes typ 1. Studien genomfördes som en systematiskt litteraturstudie med kvalitativ metod med en induktiv manifest design. Under databearbetningen framkom fem teman: upplevd rädsla, upplevelser av bristande kunskap, upplevelser av egenvård, upplevda svårigheter samt upplevelser av relationer och stöd. Resultatet i studien belyser svårigheter med egenvård, rädslor relaterade till sjukdomen, att känna sig annorlunda, svårigheter med att avslöja sin sjukdom, att känna sig dömd av andra på grund av deras okunskap, bristen på stöd och dåligt bemötande från vårdpersonal. Dessa upplevelser är viktig kunskap för sjuksköterskor för att ge en god omvårdnad och det kan vara intressant att genomföra vidare forskning kring hur individer upplever sjuksköterskans stöd samt vad sjuksköterskan kan göra för att främja egenvård. / In 2012, 1,5 million people died due to diabetes and the prevalence of the disease increases worldwide all the time. Type 1 diabetes is considered the most serious type of diabetes and every year 400 people in the ages 15-34 sicken in the disease. The individual must manage 95% of their diabetes management which puts him or her to be faced with a lot of demands to perform different kinds of lifestyle changes. The aim of this study was to illustrate young adults’ experiences of living with type 1 diabetes. The study was performed as a literature study with a qualitative methodology and inductive manifest design. In the data analysis five categories emerged: experienced fear, experiences of lack of knowledge, experiences of self-care management and experiences of relationships and support. The result of this study highlights the difficulties of self-care management, fears related to the disease, feeling different, the difficulties of disclosing the disease, feeling judged by others because of their lack of knowledge, lack of support and bad treatment from healthcare professionals. These experiences are important knowledge for nurses to give a good nurturance and it could be interesting to do further research about how individuals experience the support from the nurse and what the nurse can do to promote self-management.

Type 1 diabetes (T1D) results from a loss of functional insulin-producing pancreatic beta cells. The etiology of T1D is poorly understood, but the detection of infiltrating inflammatory cells in the pancreas and circulating autoantibodies has led to the common notion that an autoimmune process plays a central role in the pathogenesis of the disease. The aim of this doctoral thesis was to assess various aspects of the immunopathology of type 1 diabetes. To this purpose, studies have been conducted on pancreatic material from the Network for Pancreatic Organ Donors with Diabetes (nPOD) collection, the Nordic Network for Islet Transplantation, and the Diabetes Virus Detection (DiViD) study. Paper I is a study on pancreatic tissue from organ donors with varying duration of T1D as well as non-diabetic donors and subjects with other types of diabetes, in which persistent expression of glucose transporters was shown on the beta cell membrane despite several years of T1D. Glucose transporter 1 was also confirmed as the predominant glucose transporter on human pancreatic islets. In paper II, we report on signs of inflammation in the exocrine but not in the endocrine pancreas in non-diabetic organ donors with diabetes-related autoantibodies, suggesting that diabetes-associated autoantibodies can occur in response to unspecific pancreatic lesions. Paper III aimed to characterize the T cell-infiltration of pancreatic islets in material from recent-onset T1D patients. Insulitis was shown in all subjects, but with distinct differences in expression analysis of T- and B cell activation to cell-mediated allorejected kidney transplant. Also Paper IV was conducted on material from recent-onset cases and showed increased islet glucagon content, in combination with a reduced number of islets but sustained mean islet size. Together, these results provide expansion of our knowledge of the immunopathology in T1D, and will hopefully assist in bringing us towards a deeper understanding of T1D aetiology and eventually an effective cure.

Background: Pancreatic islet transplantation for type-1 diabetes has resulted in considerable success over the past decade. However, the worldwide shortage of pancreatic donors remains a major challenge. In an attempt to expand the donor pool, pancreases from obese organs donors (>30 kg/m²) are now routinely offered to islet transplantation in the UK. In addition, it has been suggested that pancreases from donors with early type-2 diabetes mellitus may also be suitable. However, for both these donor groups, although high islet yields (IEQ) may be obtained, it is unclear whether these islets function optimally. An additional approach to the donor shortage is to minimise the number of donors required per islet recipient. One strategy to achieve this is to use different pharmacological agents to enhance post-transplant islet function. Aims: The aims of this thesis were fourfold; 1) To determine whether islets isolated from high BMI donors function normally in vitro and in vivo; 2) To establish why islet yields are higher from obese donors; 3) To determine whether islets from donors with type-2 diabetes are suitable for islet transplantation; 4) To investigate whether glucagon-like peptide 1 receptor agonist therapy improves post-transplant islet graft function. Results: Stimulated insulin and glucagon secretion, and markers of mitochondrial function (intra-islet ATP content and mitochondrial copy number) were compared in islets isolated from obese (BMI>30kg/m²; n= 27) and non-obese (BMI<28kg/m²; n=25) donors. No differences in secretory function or intra-islet ATP were observed between the two groups. Pancreatic lipid and intra-islet triglyceride concentrations were higher in the obese group. In vivo clinical outcomes of patients transplanted in Oxford and a larger cohort (n=35) in Edmonton, Canada with islets from obese or non-obese donors showed no differences in post-transplant outcomes. Improved islet yields were shown to be a result of improved islet recovery of larger islets, in obese donors. Abnormal insulin and glucagon secretory responses were observed in islets from type-2 diabetic subjects (n=6) and islet amyloid content was significantly higher in diabetes. The glucagon-like peptide 1 receptor agonist, exenatide, administered for 20 weeks, significantly improved graft function in patients whom islet function was impaired. Conclusion: The high lipid environment of islets isolated from donors with high BMI appears not to be deleterious to their function either in vitro or when transplanted, supporting the use of islets from high BMI donors for clinical islet transplantation. However, islet dysfunction and pathological changes indicate that islets from type-2 diabetic donors are unsuitable. Therapeutic options such as exenatide, improve transplanted islet viability and function, and could have a significant role in the future of beta-cell replacement therapy for type-1 diabetes.

Type 1 diabetes is one of the most common pediatric chronic illnesses. Adolescents are at risk for poorer glycemic control; however, youth whose parents remain involved in diabetes care are in better control. The current study examined parental involvement (PI) using a multi-method, multi-source approach in a sample of 255 youth (Age M = 12.83). The Diabetes Family Responsibility Questionnaire, Parental Monitoring of Diabetes Care Scale, and 24-Hour Diabetes Interview assessed two types of PI, parental responsibility and parental monitoring. Global and specific assessment served to cross-corroborate indicators of PI related to HbA1c. Higher levels of monitoring related to lower HbA1c for both parent- and youth-report; however, the effect decreased after controlling for socioeconomic status (SES). Additionally, monitoring mediated the relation between age and HbA1c. Controlling for SES, youth whose parents demonstrated higher levels of monitoring were in better glycemic control. Both research and clinical implications are discussed.

Objectives: The rate and impact of depressive symptoms were examined with two models based on known effects of depression on variables related to diabetes management, parental involvement and diabetes conflict. The proposed models will measure potential effects high maternal depressive symptoms may have on parental monitoring and involvement and diabetes specific conflict and how these variables may in turn relate to poor regimen adherence. Methods: Participants included 225 mothers and young adolescents (aged 11-14) with T1D. Diabetes self-care behaviors were measured with the 24 Hour Recall Interview, parental involvement and monitoring were measured with the Parent Management of Diabetes Scale, and diabetes specific conflict was measured with the Diabetes Family Conflict Scale. Results: A significant portion of mothers (21%) reported clinically elevated levels of depressive symptoms. These high levels of depressive symptoms were related to low levels of parental involvement with diabetes care (r = -.19, p < .01). Depressive symptoms were indirectly related to lower frequency of blood glucose monitoring (C.95 = -.03, -.002), insulin use (C.95 = -.01, -.0007), and meals (C.95 = -.02, -.002) through low levels of parental involvement. Higher levels of depressive symptoms were also related to higher levels of diabetes specific conflict (r = .16, p < .01), however, this relationship did not have a significant indirect effect on frequency of self-care behaviors. Conclusions: A significant portion of mothers in the current sample reported symptoms of depression above the clinical cutoff. Mothers that reported higher levels of depressive symptoms also reported lower levels of parental involvement in management of disease-care behaviors. Low levels of parental involvement mediated a significant relation between depressive symptoms and less frequent disease-care behaviors. Diabetes conflict did not mediate a relation between depressive symptoms and disease-care behaviors. These findings suggest that the reported high levels of maternal depressive symptoms among mothers of children with T1D may interfere with good diabetes management through low parental involvement. Individual treatment for depressive symptoms and interventions targeted at increasing parental involvement without increasing diabetes conflict could help improve regimen adherence.

The aim of the current study was to examine the associations among youth diabetes self-efficacy, family conflict, disease care and glycemic control via a comprehensive path model. Data were from a baseline assessment of a longitudinal RCT of 257 adolescent/parent dyads (adolescents aged 11–14). Each member of the dyad separately completed the Self-efficacy for Diabetes Self-Management Scale, Family Environment Conflict subscale, Diabetes Family Conflict Scale, Diabetes Behavior Rating Scale, and 24-hr Diabetes Interview Blood Glucose Frequency subscale. Additionally, a biological marker of glycemic control, or HbA1c, and relevant demographic variables were collected. A mediation model found higher youth diabetes self-efficacy mediated the link between lower family conflict and better disease care (β = -.08, p <.01) to glycemic control (β = .05, p <.05.). Further, the relation of higher self-efficacy to better glycemic control was mediated by better disease care (β = -.06, p <.05). Higher youth diabetes self-efficacy (β = -.16, p <.05), lower family conflict (β = .19, p <.001), and better disease care (β = -.17, p <.01) each were directly related to better glycemic control. The overall model with relevant demographic factors fit the data well [χ² (2) = .50, p = .78, CFI = 1.00, RMSEA= .00] and accounted for 13% of the variance in self-efficacy, 32% of the variance for disease care, and 25% of the variance in glycemic control. Interventions that target better youth diabetes self-efficacy and lower family conflict concurrently may promote better disease care and glycemic control.

Objective: Type 1 diabetes is one of the most common pediatric chronic illnesses. Adolescents are at risk for poorer adherence and in turn, poorer glycemic control; however, youth whose parents remain involved in diabetes care are in better control. A parent’s level of involvement is dependent in part upon his or her own social and emotional functioning. Much is known about the link between separate aspects of parent psychosocial functioning (e.g., depressive symptoms, parental stress) and parent involvement in diabetes care, adherence, and glycemic control. However, no study to our knowledge has examined these constructs simultaneously as they interrelate to one another and to youth diabetes status. Given the complexity of human behavior, use of multiple indicators of parent psychosocial status should provide a comprehensive portrayal of precursors to parental monitoring. Methods: The current study used structural equation modeling (SEM) in a sample of 257 parent-youth (aged 11-14) dyads (91% mothers) to examine comprehensive parent psychosocial functioning including parental distress, authoritative parenting, and parental self-efficacy for diabetes management as related to parental monitoring, youth adherence and glycemic control. Results: The SEM model fit the data well [χ2 (121) = 209.24, p < .001, CFI = .93, TLI = .91, RMSEA = .06, SRMR = .08]. Overall, the model accounted for 30% of the variance in parental monitoring, 27% of the variance in adherence, and 22% of the variance in glycemic control. Specifically, lower levels of parental distress (i.e., depressive symptoms, parenting stress, and hypoglycemic fear) related to higher parental self-efficacy for diabetes management and more authoritative parenting, each of which in turn related to more parental monitoring. Further, higher parental self-efficacy related directly to better youth adherence. Conclusions: The current study shows interrelated paths of parent psychosocial functioning associated with parental monitoring of youth diabetes care and ultimately, youth adherence and glycemic control. Interventions that target diabetes adherence in adolescents with T1D should consider screening for and treatment of parental distress.

The Test of Diabetes Knowledge (TDK) was studied to determine its appropriateness for children. Early onset diabetes was examined for residual effects on poorer adolescent understanding of diabetes and problem solving that could affect self-care behaviors. Participant groups were created as children (<12) and adolescents (≥12). A second division created a group of adolescents with early onset disease (EOD < 12 years) and with late onset disease (LOD >12 years). Participants were predominantly Caucasian and from middle class families. 51% were boys with an average age of 12.95 years, disease duration of 4.35 years and onset age of 8.58 years. Children scored significantly lower and responded “I don’t know” significantly more often for all levels of knowledge when compared to adolescents. EOD and LOD group differences in problem-solving knowledge were not found for adolescents, although duration accounted for a significant amount of variance in the model. Post-hoc regression indicated a significant negative relationship between duration and knowledge. EOD and LOD group differences were not found in self-care behaviors. The TDK does not appear to be developmentally appropriate for children. EOD adolescents do not differ from LOD adolescents on problem solving questions; mean scores indicate the lack of abstract knowledge seen in children may be resolved with the transition into adolescence. Results indicate the longer a child has diabetes the less knowledge they appear to retain.