Article

Erratum to: Perceived Diabetes Task Competence Mediates the Relationship of Both Negative and Positive Affect with Blood Glucose in Adolescents with Type 1 Diabetes

Department of Psychology, University of Utah, Salt Lake City, UT, USA.
Annals of Behavioral Medicine (Impact Factor: 4.2). 03/2009; 37(1):1-9. DOI: 10.1007/s12160-009-9086-7
Source: PubMed
ABSTRACT
Adolescents dealing with type 1 diabetes experience disruptions in affect and diabetes management that may influence their blood glucose.
A daily diary format examined whether daily fluctuations in both negative and positive affect were associated with adolescents' perceived diabetes task competence (DTC) and blood glucose, and whether perceived DTC mediated the relationship between daily affect and blood glucose.
Sixty-two adolescents with type 1 diabetes completed a 2-week daily diary, which included daily measures of affect and perceived DTC, then recorded their blood glucose readings at the end of the day. We utilized hierarchical linear modeling to examine whether daily perceived DTC mediated the relationship between daily emotion and blood glucose.
Daily perceived DTC mediated the relationship of both negative and positive affect with daily blood glucose.
This study suggests that within the ongoing process of self-regulation, daily affect may be associated with blood glucose by influencing adolescents' perception of competence on daily diabetes tasks.

Full-text

Available from: Deborah J Wiebe, Apr 05, 2015
ORIGINAL ARTICLE
Perceived Diabetes Task Competen ce Mediates
the Relation ship of both Negative and Positive Affect
with Blood Glucose in Adolescents with Type 1 Diabetes
Katherine T. Fortenberry, M.S. & Jorie M. Butler, Ph.D. & Jonathan Butner, Ph.D. &
Cynthia A. Ber g, Ph.D. & Renn Upchurch, Ph.D. & Deborah J. Wiebe, Ph.D.
#
The Society of Behavioral Medicine 2009
Abstract
Background Adolescents dealing with type 1 diabetes
experience disruptions in affect and diabetes management
that may influence their blood glucose.
Purpose A daily diary format examined whether daily
fluctuations in both negative and positive affect were associated
with adolescents perceived diabetes task competence (DTC)
and blood glucose, and whethe r perceived DTC mediated the
relationship between daily affect and blood glucose.
Methods Sixty-two adolescents with type 1 diabetes com-
pleted a 2-week daily diary, which included daily measures
of affect and perceived DTC, then recorded their blood
glucose readings at the end of the day. We utilized
hierarchical linear modeling to examine whether daily
perceived DTC mediated the relationship between daily
emotion and blood glucose.
Results Daily perceived DTC mediated the relationship of
both negative and positive affect with daily blood glucose.
Conclusions This study suggests that within the ongoin g
process of self-regulation, daily affect may be associated
with blood glucose by influencing adolescents perception
of competence on daily diabetes tasks.
Keywords Adolescence
.
Daily affect
.
Blood glucose
.
Diabetes management
.
Diary
Introduction
Type 1 diabetes is one of the most common childhood
chronic illnesses i n the United States [1]. It has an
extremely complex treatment regimen [2] involving the
coordination of multiple daily blood glucose tests, multiple
daily insulin injections or insulin provided through a pump,
and monitoring diet and daily exercise levels in order to
normalize blood glucose levels [3]. Adequate diabetes
management during adolescence is often a struggle, with
adherence and blood glucose control commonly decreasing
during this developmental period [4], raising the potential
of serious long-term complications [5]. The greater negative
affect and affect lability that occurs during adolescence [6,
7] may present additional challenges for the adolescent, as
negative affect may derail both diabetes management [8]
and blood glucose control [9]. In this study, we sought to
examine whether adolescents perceptions of how well they
managed their diabetes on a given daywhich we label
perceived diabetes task competence (DTC)mediated the
relationship between daily affect and blood glucose levels.
Overwhelming evidence utilizing a variety of measures
of negative affect points to the strong influences of negative
emotions on health and health outcomes [1012]. This
relation is particularly relevant for adolescents with diabetes,
who report negative emotions to be a common diabetes-
related stressor [13]. Wiebe and colleagues found trait
anxiety among adolescents with diabetes was associated
with several self-regulatory processes that undermined
glycemic control [14]. Consistent relationships between
depressive symptoms and poorer metabolic control have
been reported in both adult [15, 16] and adolescent samples
[17]. The adult literature also suggests an association
between blood glucose and daily stress, which may relate
to increased negative emotion. In adults with type 1 diabetes,
ann. behav. med.
DOI 10.1007/s12160-009-9086-7
K. T. Fortenberry (*)
:
J. M. Butler
:
J. Butner
:
C. A. Berg
:
R. Upchurch
Department of Psychology, University of Utah,
Salt Lake City, UT, USA
e-mail: katie.fortenberry@psych.utah.edu
D. J. Wiebe
Department of Psychiatry,
University of Texas Dallas Southwestern Medical Center,
Dallas, TX, USA
Page 1
higher daily stress was associated with higher daily blood
glucose levels [16] as well as with higher glycosylated
hemoglobin levels following the study [18]. Gonder-
Frederick and colleagues [19] also found that higher daily
levels of blood glucose in a sample of adults with Type 1
diabetes was associated with negative affect, specifically
anger and sadness.
The link between emotions and glycemic control in
adolescents may occur through adolescents perceptions of
competence at dealing wi th daily diabetes management
tasks, which may be affected by negative or positive affect.
These perceptions of competence may reflect a combination
of actual diabetes management behaviors and adolescents
developing perception s of the effe ctivene ss of thos e
behaviors. Negative emotions are associated with adolescent
reports of poorer diabetes management across a number of
studies [20, 21]. In a sample of adolescents with type 1
diabetes, Stewart and colleagues found evidence supporting
a pathway leading from overall emotional distress to poorer
glycemic control via lower self-efficacy and reports of
poorer diabetes management [22], and this pathway was
supported longitudinally in a 1- to 2-year follow-up [23].
Little is understood, ho wever, about how adolescents
negative affect, perceptions of competence with respect to
diabetes tasks, and blood glucose may play out in the day-to-
day life of adolescents coping with diabetes, which is likely
to be important because management of diabetes occurs at an
ongoing daily level. An important contribution of the present
study was to examine daily associations between emotions
and blood glucose and to examine whether perceived DTC
mediated the associations.
Less is known about how the experience of positive
emotions relates to perceptions of diabetes competence in
adolescents. Research suggests that positive and negative
emotions are conceptually distinct, as opposed to opposite
ends of a single spectrum [24] and recent theory and
research suggest positive affect has unique associations
with self-regulation and coping [25, 26]. For example,
higher levels of positive affect are associated with higher
self-efficacy for successful beha vio r in areas such as
college class performance [27] and smoking abstinence
[28]. Among adolescents with diabetes, positive emotions may
serve to enhance blood glucose control by improving adoles-
cents perceived ability to cope with challenges and hassles.
Objectives
The goal of this study was to explore whether the daily
relationship between affect and blood glucose in adoles-
cents with type 1 diabetes was mediated by daily perceived
DTC. Adolescents reported on their daily affect, perceived
competence regarding daily diabetes tasks, and blood
glucose levels for 14 days. Utilizing a daily diary approach
with adolescents with diabetes allowed for the examination
of day-to-day associations among variables of interest, as
opposed to more global, aggregated reports [29 ]. We
expected that such day-to-day associations would elucidate
the ongoing process o f self-regulation whereby positive and
negative affect are associated with blood glucose by
affecting adolescents perceived diabetes task competence.
Method
Participants
Adolescents with type 1 diabetes and their mothers were
recruited for a 2-week dail y diary study through patient
registries at an outpatient pediatric endocrinology clinic.
Participants were recruited in the context of two ongoing
projects, but procedu res were identical for all participants.
Twenty-seven adolescents were recruited as part of a
previous study of adolescents with diabetes [30]. Adoles-
cents and their mothers were mailed letters introducing the
study and were then contac ted by phone to invite them to
participate in a daily diary study. Of the 42 dyads contacted,
30 participated in the study and 27 successfully completed
all of the materials. The remaining adolescents were
recruited as part of a separate study where participants
who matched the illness and demographic characteristics of
the ongoing study were mailed letters inviting them to
participate in a daily diary study and recruited during clinic
appointments. Of 49 dyads approached, 41 participated in
the study and 37 successfully completed all materials.
Across both studies, eligibility criteria included: adolescent
age between 11 and 17, diagnosed with diabetes for at least
1 year, adolescent livi ng with mother, and ability to read
and write English. These criteria were selected to ensure
that participants were capable of completing the study and
were dealing with similar problems in diabetes management
during the adolescent developmental period.
Therefore, a total of 64 children (30 females and
34 males) 11.6 to 16.3 years of age (M=14.1, SD=1.20)
with a diagnosis of type 1 diabetes of at least 1-year
duration (mean illness duration=4.6 years, SD=2.87) and
their mothers parti cipated in the study. The majority of
mothers identified themselvesasCaucasian(91.9%),
having either some college or a college degree, and a
relatively high household annual income with 75% of the
sample earning over $50,000 a year.
This study was approved by the appropriate Institutional
Review Board. Adolescents gave written assent and the
adolescents mothers gave written informed consent and
parental permission.
ann. behav. med.
Page 2
Procedure
Participants were scheduled for a 1-h training session where
they individually completed a questionnaire packet (a
subset of which was used in this study) and were trained
for comp letio n of a 14-d ay daily diary. This 2-week time
period was chosen to maximize the measurement of
problematic diabetes episodes, without jeopardizing par-
ticipant compliance. Participants were instructed to
complete their diaries at the end of each day and return
them the next day in separate postage-paid envelopes.
Participants received phone calls by research assistants at
least every ot he r day to enc our ag e pa rticip a tion, ad dr ess
questions, and resolve problems in the completion of
received diaries. Participants were paid $10 each for
completing the questionnaire pa cke t and $3 for eac h
daily diary form ret urned. Of the 64 participants, 29
returned all 14 diaries fully completed, and 35 missed
between 1 and 10 days (M=3 days). To be included in the
analyses, dyads must have completed at least three
consecutive daily diaries. On average, mothers completed
13 and teens completed 12 out of 14 diaries. Participants
who complete d al l 14 di ar y day s di d not d iffer fr om th ose
who missed diary days based on household income, child
age or gender, or length of time diagnosed with diabetes
(ts([62]<1.7, ps>0.10).
Daily Diary Measures
Perceived Diabetes Task Competence
To measure th e adolescents perceived competence in
managing daily diabetes tasks, adolescents initially com-
pleted a brief checklist indicating how well they handled
each of ten challenging aspects of diabetes management
(e.g., glucose testing, administering correct insulin dose,
eating appropriate foods at the proper times, eating regular
snacks, avoiding high blood glucose). Participants rated
how well each task was performed that day using a 1 (did
not do well) to 5 (did very well) scale. Items were generated
from the Self-Care Inventory [31], diab et es tr eat m ent
recommendations [32], and the common diabetes problems
that children and mothers reported in a preliminary study
[13]. To examine stability in perceived DTC across days,
we used the Spearman-Brown prediction formula [33]
which corrects for changes in reliability with repeated
administrations of a measure. This indicated a within-
person testretes t reliability of 0.77, sugge sting that
individuals were moderately consistent across days around
their own mean. Please see Table 1 for means and standard
deviations of all key variables. Means for daily variables
are provided across days and subjects.
Daily Affect
At the end of each daily diary, adolescents reported their
daily mood using the Positive and Negative Affect
Schedule [34]. This measure consists of ten positive
emotions (e.g., alert, interested, enthusiastic) and ten
negative emotions (e.g., anxious, angry, distressed) rated
on a 1 (slightly) to 5 (extremely) scale to describe how
much the adolescent experienced each emotion on each
day. The SpearmanBrown prediction formula indicated
within-person testretest reliability was quite consistent
across the 14 days, with reliabilities for positive and
negative affect of 0.84 and 0.64, respectively.
Daily Average Blood Glucose
At the end of the daily diary, adolescents were asked to
record each blood glucose reading taken off their glucom-
eters at the end of each day and the average blood glucose
level for each day was computed. Adolescents recorded
between 1 and 6 blood glucose readings per day (average of
3.4; SD=1.8), with considerable variability across days
(SpearmanBrown corrected reliability of 0.49). It should
be noted that the average blood glucose level of 190.97
(SD=72.69) is above the 180 mg/dl level considered
hyperglycemic [35].
Single-Item Daily Variables
At the end of each daily diary, adolescents were asked
several questions to gain a better understanding of daily
perceptions of their diabetes management and to validate
the interpretation of the perceived DTC variable. These
included confidence related to diabetes management (How
confident were you in your ability to manage diabetes?)
and diabetes-related control (Overall, how much control
did you have over your diabetes management today?).
Table 1 Means and standard deviations of key variables
Mean SD Range
Perceived DTC 4.05 0.63 2.15.0
Positive affect 2.66 0.95 15
Negative affect 1.62 0.59 14.5
Daily blood glucose 190.97 72.69 31528
Daily diabetes confidence 3.93 1.00 15
Daily diabetes control 3.86 0.94 15
Depression 5.08 4.21 022
Diabetes self-efficacy 5.29 3.08 3.086.0
Perceived adherence 3.88 0.52 2.364.86
ann. behav. med.
Page 3
These items were rated on a 1 (strongly disagree) to 5
(strongly agree) scale.
Questionnaire Measures
Demographic and Illness Information
Mothers completed a demographics questionnaire that
included personal and family information (chil d s age and
sex, ethnicity, household income, parental marital status,
parental education, and religious affiliation) as well as
illness information (duration of illness, age at diagnosis).
Diabetes Self-Efficacy
The following two measures were included to examine the
convergent validity of the perceived DTC variable. The Self-
Efficacy for Diabetes Management Scale [36] assessed
adolescents perceptions of their ability to manage diabetes
across 35 problematic situations on a 1 (very sure I cant) to 6
(very sure I can) scale. We reduced the scale to 12 items in
order to minimize redundancy and update content. In our
sample, this scale had good internal consistency (alpha=0.89).
Perceived Adherence
Adolescents completed the 14-item Self Care Inventory
[31] to assess adherence to various aspects of the diabetes
regimen over the preceding month (e.g., Over the past
month, how well have you followed recommendations for
glucose testing?). Adolescents rated their adherence on a 1
(never) to 5 (always) scale. Total scores on this scale have
adequate internal consistency (alphas>0.76; [30, 37]) and
correlate well with more time-intensive interview methods for
measuring adherence [38]. Within this sample, alpha=0.82.
Statistical Model and Analyses
The diary design provided 14 daily reports of negative and
positive affect, percei ved diabetes task competence, and
blood glucose. Hierarchical linear analyses were used [39]
to conduct the analyses in two phases. First, we examined
the convergent validity of the perceived DTC variable by
examining associations with additional variables pertaining
to adolescents perceptions of diabetes management. Second,
we examine the associations of negative affect and positive
affect with blood glucose, and whether perceived DTC
mediated those associations. This procedure interpolates the
missing data under the assumption that it is missing at
random (MAR) [40]. The se models were based on a
multilevel data array of i adolescents on j days. Two models
like those depicted in Fig. 1 were calculated, one for positive
and one for negative affect [41] depicting the total effect of
affect on blood glucose as c = c + ab.
Consistent with mediational analyses [41], we began by
establishing that within person across day fluctuations in
negative affect (NA), positive affect (PA), and perceived DTC
were associated with within person, across day fluctuations in
average blood glucose. NA, PA, and perceived DTC were all
centered at the group mean (i.e., within person). The day the
Note: Bracketed coefficients represent coefficients from the original level 1 equations that do not
include pathways a and b simultaneously in the model. All other coefficients are from the
complete stacked model. Standard errors of the coefficients are in parentheses. c = c’ + ab +
ab
where the average mediation effect is ab +
ab
. Day was included as a covariate in the model but
pathways were nonsignificant and thus it is not depicted in the figure.
***
p
< .001 **
p
< .01; *
p
< .05.
Positive
Affect
Perceived
DTC
.15***(.03) 50.51***(6.33)
Daily Blood
Glucose
Perceived
DTC
-.22***(.05)
Negative
Affect
50.66***(6.59)
Daily Blood
Glucose
{13.46**} .57 (4.82)
{-18.03**} -3.25 (3.67)
c’
c’
a
a
b
b
ab
a
σ
σ
σ
σ
Fig. 1 Perceived DTC mediates
the relationships of both PA and
NA with blood glucose
ann. behav. med.
Page 4
measure was completed (day 0, day 1, day 2 where 0 was the
first day) and was used as a covariate to remove linear trends
in blood glucose. The equations listed below illustrate these
three separate analyses:
Level 1 Blood Glucose
ij
=B
0i
+B
1i
(Day
ij
)+B
2i
(NA
ij
)+r
ij
Level 1 Blood Glucose
ij
=B
0i
+B
1i
(Day
ij
)+B
2i
(PA
ij
)+r
ij
Level 1 Blood Glucose
ij
=B
0i
+B
1i
(Day
ij
)+B
2i
(perceived
DTC
ij
)+r
ij
In these equations, mean blood glucose levels for
participant i for day j are predicted by variables B
0i
, which
represents the blood glucose level for a participant when the
variable in the equation (e.g., NA) is 0 on the first day
(when day is 0), B
1i
represents the relationship between
diary day and blood glucose level for subject i across days,
B
2i
represents the relation between NA (or in the subse-
quent models, PA or perceived DTC) and blood glucose
means across days for each subject, and r represents
variation in blood glucose due to measurement error.
Mediation models examining whether the quality of
perceived DTC-mediated relationships between dail y affect
(negative and positive) and daily average blood glucose
levels were tested using a procedure that controls for
covariance between the indirect mediation paths [42]. This
is necessary b ecause when analyzing mediation using
random effects models, the average fixed effects are biased
to the extent that there is covariance between the two
mediation components (e.g., if there is covariance between
the weights for the negative affectperceived DTC path
and the perceived DTC-blood glucose path [42, 43]) .To
address this bias, we followed the procedures outlined by
Bauer and colleagues [42]. This involved simultaneously
modeling the regression predicting the mediator (how affect
predicts perceived DTC) and the outcome (how affect and
perceived DTC predict blood glucose levels). The full
model with all covariates for the HLM analyses establishing
the relationship between perceived DTC and NA can be
expressed in the following Level 1 equation. The analyses
for PA are similar in structure and are not illustrated:
Level 1 Z
ij
=B
1i
(OI
ij
)+B
2i
(OI
ij
*NA
ij
)+B
3i
(OI
ij
* per-
ceived DTC
ij
)+B
ij
(MI
ij
)+B
ij
(MI
ij*
NA
ij
)+B
ij
(MI
ij*
Day
ij
)+B
ij
(OI
ij*
Day
ij
)+r
ij
In these equations, mediator indicators (MI) and out-
come indicators (OI) represent redundant dummy codes
(when one is zero the other is one) and Z represents a
stacked variable that reflects average daily blood glucose
when the dummy coded OI is 1 and perceived DTC when
OI is 0 for participant i on day j. All predictors were grand
centered (at the sample mean) to facilitate interpretation in
the mediation co ntext. Inclusion of a heterogeneous error
structure allowed separate error variances for the mediator
as DV and outcome as DV. We present a confidence interval
method to establish the significance of the mediation
(outlined in [42]).
Results
Convergent Validity of Perceived DTC
In order to better understand the perceived DTC variable,
comparisons were made with additional variables examin-
ing adolescents perceptions of their diabetes management
on both daily and global levels. First, comparisons were
made with the single-item variables examining daily
perceptions of diabetes-related control and confidence.
Using the single-item variables as the dependent variable
in separate HLM analyses, perceived DTC was associated
with more daily perceived diabetes-related control (B=1.18
[SE=0.09], p<0.001 ), and more da ily confidence in
handling diabetes (B=0.86 [SE=0.09], p<0.001). Second,
to examine associations with global perceptions of adherence
and diabetes self-efficacy, separate analyses were conducted
with perceived DTC as the dependent variable to ascertain
the influence of global variables on the intercept. Perceived
DTC was positively associated with both perceived adher-
ence (B=0.54 [SE=0.09], p<0.001), and diabetes self-
efficacy (B=0.52 [SE=0.16], p<0.001). That is, individuals
who reported higher adherence and diabetes self-efficacy
also reported higher DTC on average across the 14 days.
These findings are similar to those we have found using a
parallel measure of perceived DTC in a separate sample [44].
The associations of perceived DTC with variables that were
developed to reflect both cognitive perceptions of compe-
tence, as well as freque ncy of dia betes manage ment
behaviors, suggests perceived DTC taps into aspects of both
diabetes management behaviors and self-efficacy beliefs
regarding ability to sustain those behaviors.
Perceived DTC Mediates the Daily Associations
Between Affect and Blood Glucose
In Table 2, the results of the three Level 1 HLM analyses
are presented. For the model predicting blood glucose from
NA (top panel), NA was associated with higher (less
healthy) same day blood glucose. For the model predicting
blood glucose from PA (middle panel), PA was associated
with lower (healthier levels of) same day blood glucose.
For the model predicting BG from perceived DTC (bottom
panel), perceived DTC was associated with lower (healthier
levels of) same day blood glucose. Day was not a
significant predictor of blood glucose in any model, nor
was day a predictor of perceived DTC.
As shown in Fig. 1 pathway c, reports of NA did not
significantly predict blood glucose once perceived DTC
was included in the model, indicating that the relationship
between NA and blood glucose was explained by the
relationship between NA and poorer perceived DTC. The
results of the parallel model examining PA indicated that
ann. behav. med.
Page 5
reports of PA did not significantly predict daily blood
glucose once perceived DTC was included in the model.
The relationship between PA and blood glucose was
explained by better perceived DTC when higher levels of
PA were reported. Thus, on a daily basis, percei ved DTC
mediates the association of both NA and PA with daily
blood glucose.
We constructed 95% confidence intervals of the media-
tion effect taki ng σ
ab
into account [41]. This replaces the
Sobel test when σ
ab
is non-zero, as was the case here (σ
ab
for NA=3.11, Z=39.29, p<0.01; σ
ab
for PA=5.85, Z=
234.00, p<0.01). Specifically, having zero fall within the
confidence interval would indicate a pattern inconsistent
with mediationthat the popula tion mediation effect could
be zero. The results of the confidence interval test indicated
that significant mediation was present. For the NA model,
CI 95% 11.25 19.24 27.23, and for the PA model, CI
95% 19.55≤−12.95≤−6.34. Once the relationship be-
tween perceived DTC and blood glucos e was included in
the model, the relationships between NA and blood
glucose, and PA and blood glucose, respectively, were no
longer significant, indicating significant mediation.
To examine whether there was a lagged association
between affect and perceived DTC or between affect and
blood glucose (i.e., whether affect on Day t predicts
perceived DTC/blood glucose on Day t+1), the models
displayed above were extended so that next day perceived
DTC (or blood glucose) was predicted from previous days
affect (NA or PA) while controlling for previous days
perceived DTC (or blood glucose). No significant effect of
NA or PA was found for either next day perceived DTC or
next day blood glucose (Bs<0.10, ps>0.10). Lag analyses
were repeated examining the reverse pathway, to determine
whether next days affect (NA or PA) was predicted from
previous days perceived DTC (or blood glucose) while
controlling for previous days affect. Again, no significant
effect of perceived DTC or blood glucose was found for
either next day NA or PA (Bs<0.01, ps>0.10). Therefore,
lagged analyses were unable to provide evidence for
supporting causality in either direction.
Finally, to examine whether the associations of PA and
NA were independent when both were included in the
model, we also tested each model including both PA and
NA and the pattern of results remained the same. There was
no significant interaction between PA and NA for either
perceived DTC (B=0.05 [SE=0.06], p=0.39) or blood
glucose (B=5.68 [SE=10.84], p=0.60) as the outcome.
This analysis supported the idea that PA and NA are best
considered as having independent associations with per-
ceived DTC and blood glucose.
Discussion
The goal of this study was to examine self-regulatory
processes in blood glucose control involving affect and
perceptions of competence in managing diabetes problems.
Both theory [45, 46] and research [47, 48] reveal the
importance of emotion in illness-related perceptions and
outcomes. This study provides evidence that emotion may
disrupt or facilitate management of healthy blood glucose
levels in adolescents with diabetes. Emotion regulation and
perceptions o f competence and self-efficacy in management
are especially important during adolescence, and may
partially explain the poorer metabolic control seen in
adolescents with diabetes [4
, 49]. Our results indicate that
daily perceived DTC mediated the same-day relations hip of
both negative affect and positive affect with daily average
blood glucose. The daily diary format is a unique method of
capturing everyday life experiences [50], which may be
particularly relevant in an illness requiring ongoing daily
management such as diabetes.
The proposed pathway from emotions to blood glucose
via perceived DTC is consistent with evidence that
emotions can both impair and facilitate self-regulation.
Negative emotions may influence appraisal processes that
are important for behavioral self-regulation. It is feasible
that a broader tendency to report negative affect could
explain the relationship between daily affective experiences
and perceived DTC. For example, some adolescents might
tend to report both negative affect and negative perceived
DTC due to an underlying trait, such as neuroticism.
Intraindividual fluctuations in affect and behavior are
thought to be influenced by trait-like characteristics [51 ].
Study of these intraindividual fluctuations across days and
times indicates that the degree of within-person fluctuation
in both affect and behavior is high, and likely reflects
Table 2 Associations of daily negative affect, positive affect, and
perceived DTC with blood glucose
Coefficient (SE)
MODEL blood glucose predicted from negative affect
Intercept 193.17* 7.09
Day 0.20 0.53
Negative affect 13.46** 5.44
MODEL blood glucose predicted from positive emotion
Intercept 194.53* 7.02
Day 0.43 0.54
Positive affect 18.03* 6.34
MODEL blood glucose predicted from perceived DTC
Intercept 193.15* 7.54
Day 0.15 0.50
Diabetes Task Management 0.53.16* 7.03
*p<0.01; **p<0.05
ann. behav. med.
Page 6
situation-based factors [51, 52]. The link between positive
affect and behavior is unlikely to be explained by underlying
neuroticism, but may reflect an underlying trait related to
positive affect, such as extraversion. Although it is plausible
for our data to be explained, in part, by underlying trait-
influenced processes, it is unlikely for the overall pattern of
findings to be explained by any single trait.
Baumeister and colleagues [47] suggest that the presence
of negative emotions may limit resources in adolescents,
leading to more difficulty in managing problems related to
illness. Future research should examine whether this rela-
tionship between negative emotion and illness-related prob-
lem solving found by Baumeister is related to perceived
competence in illness management. Adolescents especially
may be thwarted by negative emotions because they reason
more poorly on emotionally salient problems than do adults
[53]. Furthermore, negative emotions may become a focus of
regulatory efforts, which could undermine self-management.
The presence of negative emotions may lead adolescents to
focus on the short-term goal of feeling better emotionally,
rather than on long-term illness management [54].
A key finding is that positive affect is related to daily
blood glucose via perceived DTC. Individuals who report
positive affect in the context of difficult circumstances [55]
appraise circumstances positively and engage in self-
regulatory behavior. Furthermore, positive emotion associ-
ated with a certain health behavior is associated with
greater tendency to engage in that behavior [48]. It is
possible therefore that positive affect could increase the
resources of adolescents coping with diabetes, and enhance
perceptions of their ability to competently address difficulties
in management. The processes by which this relationship
may occur require further examination. It is worth noting
that positive and negative affect showed independent effects
in our study, pointing to the likelihood of unique associations
of different affects with self-regulatory processes.
Limitations
Several limitations of the study should be noted. First,
although longitudinal data supports the hypothesis that
daily emotions influence blood glucose via daily illness
management [23, 56], our results are unable to demonstrate
directionality. An equally plausible explanation for the
current findings is that adolescents may have received poor
blood glucose readings during the day, leading them to
perceive their diabetes management efforts for the day as
bad and to feel more negative and less posit ive emotion
(e.g., [57]), consistent with theories that negative emotions
provide information that the self-regulatory system requires
adjustment (e.g., [58 ]). Our explanation, however, is
consistent with evidence suggesting that manipulating
negative emotion (i.e., inducing fear) can undermine
important self-regulatory processes [59]. Furthermore, an
alternative model of mediation, in which daily affect
mediated the relationships between perceived DTC and
blood glucose, was not supported by our results. Next-day
lag effects, which may have been helpful in elucidating
questions of causality, were not found for either of these
directions. The lack of lag effects may be related to the
timing of our daily diary measures as affect fluctuates more
rapidly than on a 24-h cycle [7] and perceived DTC and
blood glucose fluctuate throughout the day. Moni toring
affect and perceived DTC more frequently throughout the
day may provide a clearer understanding of the direction-
ality of the mediation pathway.
Our measure of perceived DTC, although derived from a
well-validated and commonly used measure, could be
considered fairly mul tifaceted, capturing an adolescents
overall views of how well they manage their diabetes as
well as their actual diabetes management behaviors. This
measure fluctuated on a daily basis with adolescents
confidence and perceptions of control in managing diabetes.
Furthermore, adolescents who reported higher self-efficacy
beliefs and adherence also perceived higher DTC on average
across the 2-week diary. Perceived DTC may thus reflect
adolescents perceptions of their own behaviors and capabil-
ities. Finally, our method of capturing daily blood glucose by
averaging across measures within days does not capture the
nuances of blood glucose fluctuations [60] and our reliance
on the adolescents self-report of their emotions, compe-
tence, and of the blood glucose levels may be problematic.
Future Directions
In this study, only adolescent emotions and perceptions of
competence were examined. However, adolescent diabetes
care takes place within the broader family context and
extensive research shows a complex and bi-directional
relationship among family factors and diabetes in youth.
Parenting a child with diabetes impacts both mothers and
fathers emotionally [61
, 62], while higher perceived
parental burden is associated with poorer levels of HbA1c
in youth with type 1 diabetes [63]. Furthermore, family
emotion management is prospectively associated with
change in disease management in patients with type 2
diabetes [64]. In our lab, we have shown that parents
emotions are associated not only with parents perceptions
of diabetes competence, but also with the adolescents self-
perceptions [65].
Conclusion
This study emphasizes the dual challenge faced by
adolescents of simultaneously managing their emotions
ann. behav. med.
Page 7
and maintaining their perceptions of competence in the
context of a complicated medical regimen. Managing an
illness in the presence of emotional changes is a challenge
that adolescents will face throughout their lives, and
adolescents develop views of their competence that remain
influential throughout adulthood. Learning to manage
illness behaviors in the presence of negative emotions,
and learning to recognize and harness positive emotions for
optimal diabetes management, are skills that may have
implications for maintaining long-term health when living
with diabetes. It will be important to understand factors that
may help adolescents to regulate their behavior in the
context of emotions as well as to understand what leads
adolescents to experience more positive or negative
emotions in the context of diabetes. Helping adolescents
to optimally manage their emotions in the context of
diabetes may have imp ortant implications for clinical
interventions and lifelong diabetes control.
Acknowledgements This research was supported by grant
51000821 from the Primary Childrens Medical Center Research
Foundation awarded to Deborah J. Wiebe and Cynthia A. Berg and by
a University of Utah Research Foundation grant awarded to Deborah
J. Wiebe. Portions of this research were presented at the 2006 annual
conference of the Society for Behavioral Medicine. We thank the
patients and staff of the Utah Diabetes Center and Kathy Free, Monica
Foresman, Gary King, Rebecca Young, Devin Donaldson, and
Marejka Shaevitz for their help with data collection and entry.
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    • "Debe comentarse que el estudio por separado del afecto positivo y negativo se ha llevado a cabo y parece resultar de utilidad en otros trastornos mentales tales como la esquizofrenia (Blanchard, Mueser & Bellack 1998; Horan, Wynn, Kring, Simons & Green, 2010), el trastorno bipolar (Meyer & Baur, 2009) y trastornos relacionados con sustancias (Van Etten, Higgins, Budney & Badger, 1998). También se ha estudiado en trastornos físicos como el cáncer (Voogt et al., 2005), cardiopatías (Spindler, Denollet, Kruse & Pedersen, 2009; Versteeg et al., 2009) y otros trastornos de salud (Fortenberry et al., 2009; Janicki-Deverts, Cohen, Doyle, Turner & Treanor, 2007). Teniendo en cuenta las diferentes explicaciones psicológicas referidas a la "
    [Show abstract] [Hide abstract] ABSTRACT: Since the seminal contribution of Bradburn (1969), positive and negative affect have been conceived as two independent unipolar dimensions. However, the controversy between these ideas and the supporters of a single bipolar dimension is nowadays still alive. In this review we identify two problems. The first one is of a conceptual nature, because, as Russell and Carroll (1999) pointed out, the term affection is not unambiguously defined and rarely researchers in this field make an explicit definition. According to Rosenberg (1988), there are at least two types of affective states, which are widely acknowledged: emotions and mood, or affective tone. Emotions are characterized for, and differ from mood in, appearing in response to an event, being intense, short-lived and specific. They are also characterized by provoking important physiological reactions in the individuals, as well as recognizable patterns of facial expression, and by determining individuals to behave congruently in relation to the emotion they are experiencing. Combining these two very different components of affect hinders the comparison of the work of different authors, and also the development of theoretical models combining the different aspects included within this concept. The second problem is related to the measurements used in the research assessing affect, where the possible existence of events or circumstances causing the affective state is not normally considered. Likewise, measurement regarding the duration of the affect are rarely performed, and objective measurements such as physiological correlates or facial expressions are not frequently collected. Consequently, instruments do not normally distinguish between mood and emotion. The aim of this paper is to review the most relevant questions regarding this debate taking into account, on the one hand, the two affective states included in the concept of affectivity (i.e., mood and emotion) and, on the other hand, the empirical and theoretical contributions provided by a wide range of disciplines such as Psychometry, Basic Psychology, neuroscience, and Clinical and Health Psychology. From Basic Psychology and Psychometry we reviewed the three fundamental argumentations advocating for an independence of positive and negative affect, as identified by Diener and Emmons (1984) and Russell and Carroll (1999): (1) that the correlation between items that evaluate the positive affect and negative affect is low, (2) that the correlation of items within the categories of positive affect and negative affect is high, and (3) that the two dimensions of affect correlate differently with other variables. A fourth argument is discussed referring to the variations of both affect types observed throughout a lifetime (Bushman & Crowley, 2010; Windsor & Anstey, 2010). From the neuro-scientific perspective we reviewed studies providing data on brain structures and neurotransmitters involved in both affect types, noting that all these studies have been carried out by inducing intense moods, which indeed might be classified as emotions rather than humor. From Psychopathology and Clinical Psychology we reviewed those disorders in which states of positive and negative mood can be experienced in a very intensive manner (positive and negative emotions), in very short periods of time and even at the same time. We also reviewed research studying the independent presence of positive and negative affect in several disorders, as well as some theoretical models on depression that indicate the possibility and desirability of adopting a 'dual' perspective in the assessment and the intervention strategies of both types of emotions in the depressive disorder and other disorders. A proposal about the reason of such contradictory findings is presented, and we suggest that research about this topic should be better conducted setting apart mood from emotions using tools that allow measuring those elements capable of distinguishing between affect types. Although the few existing studies about affective traits and mood seem to support the bipolar one-dimensional model, the conclusions drawn from the numerous investigations about emotions favor the two independent unipolar dimensions model.
    Full-text · Article · Jul 2012
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    • "Relevant to control of cognition, self-efficacy for diabetes management (i.e., belief in one's ability to manage diabetes) has consistently been related to better metabolic control (Berg et al., 2011; Iannotti et al., 2006). With respect to control of emotion, diabetesspecific negative affect (i.e., negative emotion experienced in relation to diabetes; Moss-Morris et al., 2002) is related to decreased adherence, daily blood glucose testing, and worse metabolic control (Fortenberry et al., 2009). Finally, adherence involves the ability to complete behaviors and tasks required for type 1 diabetes management (La Greca et al., 1995) and is consistently associated with better metabolic control (Hood, Peterson, Rohan, & Drotar, 2009). "
    [Show abstract] [Hide abstract] ABSTRACT: This study examined whether emotional processing (understanding emotions), self-control (regulation of thoughts, emotions, and behavior), and their interaction predicted HbA1c for adolescents with type 1 diabetes over and above diabetes-specific constructs. Self-report measures of self-control, emotional processing, self-efficacy for diabetes management, diabetes-specific negative affect, and adherence, and HbA1c from medical records were obtained from 137 adolescents with type 1 diabetes (M age = 13.48 years). Emotional processing interacted with self-control to predict HbA1c, such that when adolescents had both low emotional processing and low self-control, HbA1c was poorest. Also, both high emotional processing and self-control buffered negative effects of low capacity in the other in relation to HbA1c. The interaction of emotional processing × self-control predicted HbA1c over diabetes-specific self-efficacy, negative affect, and adherence. These findings suggest the importance of emotional processing and self-control for health outcomes in adolescents with diabetes.
    Full-text · Article · Apr 2012 · Journal of Pediatric Psychology
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    • "Discussion As anticipated from previous work (Fortenberry et al., 2009), negative affect was associated with more self-reported diabetes-related problems on a daily basis. This finding is consistent with previous literature suggesting an association between negative affect and poorer diabetes management in adolescents (Kovacs et al., 1992; Stewart et al., 2003). "
    [Show abstract] [Hide abstract] ABSTRACT: Perceived control over diabetes may serve to buffer the relationship between adolescents' experience of daily negative affect and daily problems with diabetes. In a daily diary study including 209 adolescents (ages 10.5-15.5) with type 1 diabetes, we examined how daily affect related to daily fluctuations in experience of diabetes problems, and whether perceptions of control moderated these daily associations. Using hierarchical linear modelling, we found that day-to-day experiences of negative affect were associated with more frequent daily diabetes problems. Perceptions of treatment control moderated associations between negative affect and number of problems; negative affect was more strongly associated with number of problems among teens perceiving lower versus higher treatment control over their illness. The same pattern of association was not apparent for personal control. Results suggest that perceived treatment control may help to buffer detrimental associations between negative affect and adolescents' ability to successfully manage their diabetes.
    Full-text · Article · Jan 2011 · Psychology & Health
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