1 Med. J. Cairo Univ., Vol. 80, No. 1, June: , Quality of Life Among Adolescents with Type I Diabetes Mellitus in Assiut EMAN M.M. MONAZEA, M.D.; SAHAR H. TALHA, M.D.; ETEMAD A. EL-SHEREEF, M.D.; HOSNIA S. ABD EL-MEGEED, M.D. and LOBNA F. ELTONY, M.D.* The Departments of Public Health & Community Medicine and Internal Medicine*, Faculty of Medicine, Assiut University Abstract Background: Adolescents with diabetes mellitus type 1 often describe their situation as hard because any chronic condition has an impact on aspect of life in addition to the specific illness demands. Objective: To assess quality of life (QOL) and associated factors among adolescents with type I diabetes mellitus who attended the Health Insurance Clinic in Assiut city. Subjects and Methods: A cross sectional study was conducted on diabetic students who attended the health insurance Clinic in Assiut between June, 2009 and August A modified form of Diabetes Quality of life for Youth (DQOLY) questionnaire was used. It consists of 35 items on three subscales: Worry about diabetes (9 items), impact of diabetes (15 items) and satisfaction with treatment and life (11 items). Responses to questions were scored using three-point Likert scale. Lower score indicate a poor quality of life. Cronbachcoefficient of the instrument used was 0.87 indicating its internal consistency reliability. In addition demographic and disease related data were collected. Results: A total of 396 patients aged years (mean SD 14.7± 1.9) were included in the study. Males were 54.8%. About 60% of the studied adolescents were worried about their bodies look different because of diabetes and worried to get complications. 69.5% of cases feel physically ill and 46.7% miss school because of diabetes. 43.7% of cases feel embarrassed being in public. Adolescents with diabetes duration from 1-5 years had a higher score of QOL than whose with duration >5 years (88.6±8.2vs. 86.1±7.1, p=0.01). Patients with better metabolic control had a higher score of quality of life than whose with poor control (87.2 ±8.5vs ±8.7, p=0.039). Conclusion: The impact of diabetes was readily apparent affecting physical, school and social functioning of the adolescents. Good metabolic control and intensified insulin regimen are associated with a better quality of life. So interventions to improve metabolic control and type of insulin regimen are recommended to improve QOL for all diabetic patients. Correspondence to: Dr. Eman M.M. Monazea, The Departments of Public Health & Community Medicine, Faculty of Medicine, Assiut University Key Words: Adolescents Quality of life Type 1 diabetes. Introduction THE World Health Organization defines quality of life (QOL) as: Individual s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns . QOL measure has become a vital and often required part of health outcomes appraisal. For population with chronic disease, measurement of QOL provides a meaningful way to determine the impact of health care when cure is not possible . Diabetes in children and adolescents poses serious physical, mental and emotional challenges. This is clearly due to fundamental conflicts existing between the tasks of managing diabetes and normative developmental facing the young adolescent who striving to be comfortable with rapidly maturing body, defining an identity, new role in the family, and gaining positive acceptance by peers [3,4]. Diabetes can adversely affect both psychosocial and neurocognitive functioning, thus potentially affecting the QOL of adolescent and the entire family . Children and adolescents with diabetes experience a lower QOL than those without diabetes [6-8]. Generally, Levine et al.  reported that lower QOL scores are associated with older age, poorer glycemic control, more hypoglycemic episodes, having complication, lower level of education and self reported depression and female gender. 261
2 262 Quality of Life Among Adolescents with Type I Diabetes Mellitus in Assiut Diabetic adolescents are more afraid to do appropriate developmental activities and this can have a significant impact on their progression to independence and adulthood . Consequently, it becomes important to understand how both diabetes and its management influence the adolescent s quality of life. Objective: To assess quality of life (QOL) and associated factors among adolescents with type I diabetes mellitus who attended the Health Insurance Clinic in Assiut city. Subjects and Methods A cross-sectional study was conducted in Sidi- Galal Health Insurance Clinic in Assiut city-egypt. The Diabetic clinic in health insurance is responsible for managing all diabetic students in Assiut governorate in terms of diagnosis, treatment, hospitalization, provision of drugs and health education. All diabetic school students aged years who attended the diabetes clinic between June, 2009 and August 2010 were included in the study. The students have been diagnosed as type 1 diabetics. Adolescents with coexisting chronic and psychiatric disease were excluded. A structured interviewing questionnaire was used to collect the following data from the diabetic adolescent and his/her parents: Personal data: Including age, sex and socioeconomic data which covered education and occupation of parents, crowding index and income. The socioeconomic level of the families was determined based on the scoring system of Fahmy and El-Sherbini (1983)  and classified to low, middle and high classes. Also, data about school achievement in the past year was recorded. Disease-related characteristics: Including duration of disease, number of insulin injections per day, number of hypo/hyper glycemic attacks in the past three months, number of hospital admissions in the last six months and present complications or not. Glycated hemoglobin (HBA 1 c%) was measured to determine if glycemic metabolic controlled ( 7.5) or not (>7.5) based on International Society for Pediatric and Adolescent Diabetes guidelines (ISPAD, 2009) . Diabetes Quality of life for Youth (DQOLY) questionnaire is an instrument developed and validated by Ingersoll and Marrero  to assess the quality of life of diabetic adolescents. This questionnaire was translated to Arabic and subjected to a pilot study. The pretest revealed that adolescents have found difficulties to choose between the five- point Likert scale of the questions. So the original scale was modified into only three point-likert scale ranging from 1-3. The used questionnaire consists of 35 items, divided into three sections: Worry about diabetes (9 items), impact of diabetes (15 items) and satisfaction with treatment and life (11 items). The total quality of life score was obtained from summing of all items and then the percentage total score was calculated. Lower score indicate a poor quality of life. Cronbach s alpha was used to determine the internal consistency reliability of the total score and subscale scores of the instrument and it was 0.87 for total score, 0.74 for worry, 0.74 for impact and 0.84 for satisfaction subscales. Family contribution to diabetes management: Ten questions were constructed to assess family contribution in diabetes treatment like participating in insulin injection, checking blood glucose, controlling signs and symptoms of hypo or hyperglycemia, controlling diet and encourage physical activities. The answers were scored on a 3- point scale ranging from 1-3.The lower score indicate poor family contribution. The percentage of total score was calculated. The total sum was categorized as poor ( 60%), moderate (60-80%) and good (>80%). The scale demonstrated an adequate Cronbach s internal consistency of Statistical analysis: Statistical analysis was performed with SPSS for Windows (version 16). Frequencies, percentages, means and standard deviation were calculated. Chi-square test was used for comparison between males and females. Unpaired t test and Analysis of variance (ANOVA) were used to identify factors associated with quality of life. For all statistical tests, values of p<0.05 (two-tailed) were considered statistically significant. Results A total of 396 patients were included in the study. The patients mean age was 14.7 ± 1.9 years and 54.8% were males. Most of adolescents were from rural areas (82.3%) and were in middle social class (84.3%). About half of them were in the preparatory schools. Table (1) shows the distribution of diabetic cases according to their level of worry about diabetes. The results reveal that about 60% of the studied adolescents were always or sometimes worried about their bodies look different because
3 Eman M.M. Monazea, et al. 263 of diabetes. 61.4% of cases were always or sometimes worried to get complications. Approximately 70.0% of the adolescents were not worried to get job, to complete education, to keep with friends or about their teacher behavior. There were no significant statistical differences between males and females concerning all items of worry except in getting a trip. Table (2) shows distribution of diabetic adolescents according to physical and social impact of diabetes. The table shows that the percentages of diabetic adolescents reported always or sometimes feel pain, feel physically ill or had a bad night s sleep were 64.4%, 69.5% and 52.8% respectively. Girls reported that they always felt physically ill more than boys (14.5%vs. 4.6% p=0.003). Concerning social impact, 43.7% of adolescents always or sometimes feel embarrassed being in public and 36.1% of them always or sometimes hide hypoglycemic symptoms. Also 33.6% always or sometimes eat something forbidden rather than explain their disease to the others and 22.5% of diabetic adolescents always or sometimes get teased about diabetes. Table (1): Distribution of diabetic adolescents according to their level of worry about diabetes by gender. Worry items Always Sometimes Never\rarely No. % No. % No. % How often do you worry about whether Your body looks different because of diabetes Male Female You will get complication Male Female Someone will not get out with you Male Female You will complete your education Male Female You will get the job you want Male Female You will get a trip Male Female Teachers will treat you differently Male Female Your diabetes will disrupt something in school Male Female You will keep up with your friends Male Female
4 264 Quality of Life Among Adolescents with Type I Diabetes Mellitus in Assiut Table (2): Distribution of diabetic adolescents according to physical and social impact of diabetes by gender. Item How often do you Always Sometimes Never\rarely No. % No. % No. % Feel pain associated with management Male Female Feel physically ill Male Female Have a bad night s sleep Male Female Feel embarrassed being in public Male Female Feel restricted by diet Male Female Have to explain diabetes Male Female Get teased about diabetes Male Female Eat something you shouldn t rather than explain you have diabetes Male Female Hide that you are having hypoglycemia Male Female Feel prevented from eating out with friend Male Female
5 Eman M.M. Monazea, et al. 265 As regard school impact, Table (3) shows that 46.7% of diabetic adolescents always or sometimes miss school because of diabetes and 38.9% of them reported that their disease always or sometimes interfere with exercising. The table also shows that most of diabetic adolescents always or sometimes feel that their parents were too protective (86.9%), worry too much (89.1 %) and act as they, not them have, diabetes (89.2%). Table (4) shows the distribution of diabetics according to satisfaction level with treatment and life. The table presents that most of diabetic adolescents were satisfied in all items. Girls were more dissatisfied with time spent for exercising than males (9.5%vs. 2.8% p=0.01). In other items, there were no significant differences between males and females. The percent (%) mean scores of worry, impact, satisfaction and total QOL are shown in Fig. (1). For worry it was 85.3% ± 11.3, for impact it was 76.1%±9.3, for satisfaction it was 90.8% ± 10.5 and for the total QOL it was 87.2% ±8.6. Female patients reported lower scores than males but the differences were not significant. Table (5) shows that quality of life score was not affected by age, residence or socioeconomic level. The mean score QOL was little higher for male (87.7±7.8) than for female (86.6 ±9.4) but the difference was insignificant. The table also shows that the QOL score was lower when the adolescent failed to pass the last year exam. The QOL score was significantly higher when family contribution was good (p=0.015). Table (6) shows that duration of diabetes had a significant relation to QOL (p<0.01) where mean score of QOL was higher for patients with diabetes duration 1-5 years than for those with diabetes for less than 1 years or more than 5 years. QOL significantly increased with increase number of insulin injections/day as the mean score of QOL was (86.1 ±8.3) for those injecting insulin once/day and (89.6±9.5) for those injecting insulin three times or more (p=0.001). QOL score decreased with increase number of hospital admission in the last six months. The mean score of QOL was (89.1 ±8.6) for those never admitted to hospital and (84.0± 15.4) for those admitted more than three times (p=0.02). Furthermore QOL increased among controlled diabetics. The mean score of QOL was (87.2 ±8.5) for good controlled diabetics and (80.3 ±8.7) for poor controlled (p=0.039). Table (3): Distribution of diabetic adolescents according to school and family impact of diabetes by gender. Item Always Sometimes Never\rarely No. % No. % No. % How often do you Experience interference with exercising Male Female Miss school Male Female Feel that your parents are too protective Male Female Feel that your parents worry too much Male Female Feel that your parents act as if they, not you, have diabetes Male Female
6 266 Quality of Life Among Adolescents with Type I Diabetes Mellitus in Assiut Table ( 4): Distribution of diabetic adolescents according to satisfaction level with management and life by gender. Item How satisfied are you with Dissatisfied Neutral* Satisfied No. % No. % No. % Time taken to manage diabetes Male Female Time getting check-ups Male Female Time needed to monitor your blood glucose Male Female Current treatment Male Female knowledge of your disease Male Female Time spent exercising Male Female Work and school Male Female School attendance Male Female School performance Male Female How classmates treat you Male Female Life in general Male Female *Neither satisfied nor dissatisfied.
7 Eman M.M. Monazea, et al Male Female Worry Impact Satisfaction QOL Fig. (1): The percent (%) mean scores of worry, impact, satisfaction and total QOL by sex. Table (6): Percent (%) mean score of total QOL and diseaserelated characteristics. Duration of disease (in years) No. % mean±sd of total QOL score <1 year ± years ±8.2 >5 years ±7.1 Number of insulin injection/day: Once/day ± Twice/day ±7.8 Three or more times/day ±9.5 Number of hypoglycemic attacks/last three months: Once ± Twice ±7.7 Three or more time ±8.9 Never ±9.7 Number of hyperglycemic attacks/last three months: Once ± Twice ±9.2 Three or more times ±8.5 Never ±7.9 Number of hospital admission attacks/last 6 months: Once ± Twice ±7.7 Three or more times ± 15.4 Never ±8.6 Glycemic control (HbA 1 c): Controlled ± Uncontrolled ±8.7 Table (5): Tota QOL score (% mean ±SD) by socio-demographic characteristics of diabetic adolescents. Variable No. % mean±sd of total QOL score Gender: Male ±7.8 Female ± Age (in years): years ± years ± Residence: Urban ±8.53 Rural ± Socio economic level: Low ±8.8 Moderate ± High ±5.4 School achievement: Passed ±8.6 Not passed ± Family contribution: Poor/moderate ±9.6 Good ± Discussion Adolescents with type I diabetes are challenged to adapt to a lifestyle that required self-management of dietary practices, exercise behaviors, and insulin adjustment in addition to developing autonomy and self identity . The present study revealed that the impact of diabetes was readily apparent affecting physical, school and social functioning of the adolescents. The percent mean score of impact of diabetes was 76.1±9.3 which was nearly equal to the finding of Abolfotouh et al.  in Alexandria (75.3 ± 10.2) and Graue et al. . in USA (75.3%). The major impact of diabetes was on physical activity as 69.5% feel physically ill and this was more often in girls. More than 40% of adolescents miss school because of diabetes. While social impact of diabetes was mainly due to the embarrassment felt by the adolescent. It has been suggested that diabetes may slow psychological development of adolescents, thus affecting his self image, self-esteem, and ability to play and enjoy live, share with others, set limits, renounce, identify and make commitment . Concerning worry, the total percent mean score of worry was 85.3± 11.3 compared to 77.9± 13.3 in a study conducted in Alexandria Abolfotouh et al. . Most of diabetic adolescents (61.4%) were worried more about occurrence of complications supporting the finding of Abolfotouh et al. .
8 268 Quality of Life Among Adolescents with Type I Diabetes Mellitus in Assiut The study revealed that the total percent mean of satisfaction was 90.8 ± 10.5 which is higher than reported by Abolfotouh et al.  in Alexandria (77.0± 12.5). The diabetes satisfaction items overlap with content in the other scales of worry and impact. This poses challenges about how to manage discrepancies between satisfaction and impact or worry. Satisfaction is a discrepancy measure, the discrepancy between expectation and experience, posing difficult interpretation . The results revealed that the percent mean of total QOL score was 87.2 ±8.6 which was rather satisfactory but higher than reported by Abolfotouh et al.  in Alexandria, which was 76.4 ±9.8. The difference is due to less worry and more satisfaction among our study population that may be related to difference in culture between adolescents in Lower and Upper Egypt. Concerning factors associated with QOL, the study found that female diabetic adolescents had total score QOL less than males but with no significant difference. Some studies demonstrated that diabetes had more impact on girls [16-19] whereas others found no significant differences between the two genders [14,20]. This controversy may be due to differences in culture among communities. The results also revealed no significant association between total QOL score and age, residence and family s socioeconomic status supporting the findings of [20,21]. It was concluded that the family is an integral part in treatment of diabetic patients especially among adolescents . The present study found that family involvement in diabetic care had a positive relation to total QOL, as mean % of total QOL score was 86.0 ±9.6 for patients with poor family contribution versus 88.1 ±7.7 for patients with good family contribution. This result was supported by the finding of Lewin et al. [8,23]. On the other hand, Grey et al.  fond that family contribution was accompanied by greater diabetes impact and lower satisfaction. This difference may be attributed to the manner in which parental involvement is appraised by the patient and the level of involvement . The present work demonstrated that there was a significant relationship between total score of QOL and duration of diabetes, as it decreased early in the disease and when the duration was more than 5 years. These results were in agreement with that reported by Al-Akour et al. . However, other studies confirmed that there was no significant association between duration of the disease and QOL [27,28]. Our results revealed that the frequency of hypoglycemic episodes was not significantly associated with the QOL. Abolfotouh et al.  found a similar result. However, Hoey et al. [27,29] reported in their researches that increased frequency and severity of hypoglycemia deceased total quality of life of diabetics. The difference may be due to severity of hypoglycemic episodes which not asked about it in our study. The relation between hospital admissions and QOL was expected as admission to hospital had a negative impact on social, school life and family life of diabetics [30,31]. The results revealed that QOL score decreased with increase number of hospital admission in the last six months. The mean score of QOL was (89.1 ±8.6) for those never admitted to hospital and (84.0 ± 15.4) for those admitted more than three times (p=0.02). Abolfotouh et al.  reported that poorer QOL was significantly associated with more hospital admission in the last 6 months. Intensive treatment does not worsen QOL and in some cases it is related to better QOL  (Wagner et al., 2005). Our results showed that QOL significantly increased with increase number of insulin injections/day as the mean score of QOL was (86.1 ±8.3) for those injecting insulin once/day and (89.6±9.5) for those injecting insulin three times or more. The relationship between QOL and metabolic control, measured by Hbc 1 is conflicting [33,35]. The study demonstrated that there was significant association between glycemic control and total score of QOL. The score was 87.7 ±8.5 for patients with controlled diabetes compared to 80.3 ±8.7 for uncontrolled patients (p=0.039). Vanelli et al. [28,32,34] were in agreement with our result, where they confirmed that there are relationship between glycemic controlled and total score QOL. Also, Al- Akour et al.  found that higher Hbc 1 values were associated with lower scores of QOL. Hoey et al.  reported a significant positive association exists between improved glycemic control, even over a short time period and improved QOL in patients with diabetes. Other researchers found no association between QOL and metabolic control [6,20,36]. Better glycemic control creates a sense of empowerment which facilitate coping and is reflected on better QOL . Conclusion and recommendations: The impact of diabetes was readily apparent affecting physical, school and social functioning of the adolescents. Good metabolic control and
9 Eman M.M. Monazea, et al. 269 intensified insulin regimen are associated with a better quality of life. So interventions to improve metabolic control and type of insulin regimen are recommended to improve QOL for all diabetic patients. Limitation of the study: The research was mostly descriptive, supporting the possible influence of diabetes on quality of life dimensions in adolescents. Further studies are needed to investigate the possible differences in QOL between diabetic and healthy adolescents. References 1- WHO: Study protocol for the WHO project to develop quality of life assessment instrument (WHOQOL). Q of L. Research, 2: 153-9, BERZON R.A., DONNELLY M.A., SIMPSON R.L., SIMEON G.D. and TILSON H.H.: Quality of life bibliography and indexes: 1994 update. Q. of L. Research, (4): , LINDDSTROM B. and ERIKKSON B.: Quality of life among children in the Nordic countries. Quality of life research, 12 (1): , GREYDANUS D.E. and HOFMANN A.D.: A prespective on the brittle teenage diabetic. J. Fam. Pract., (16): , DELAMATER A.M., JACOBSON A.M., ANDERSON B., COX D., EISER L., IUSTMAN P., RUBIN R., et al.: Psychosocial therapies in diabetes: report of the psychosocial working group. Dia. Care., (24): , CAMERON F.J., CLARKE C., HESKETH K., WHITE E.L., BOYCE D.F., DALTON V.L., et al.: Regional and urban Victorian diabetic Youth: clinical and quality- oflife outcomes. J. Pediatr Child. Health, 38: 593-6, GRAUE M., WENTZEL- LARSEN T., HANESTAD B.R., BATSVIK B. and SOVIK O.: Measuring self-reported, health-related, quality of life in adolescents with type I diabetes using both generic and disease-specific instruments. Acta. Paediatr, Oct., 92 (10): , FAULKNER M.S. and CHANG L.I.: Family influence on self-care, quality of life, and metabolic control in school-age children and adolescents with type I diabetes. Ped. Nurs., (1): 59-68, LEVINE B.S., ANDERSON B.J., BUTLER D.A., AN- TISDEL J.E., BRACKETT J. and LAFFEL L.: Predictors of glycemic control and short-term adverse outcomes in youth with type I diabetes. J. Pediatr., (139): , CARROLL A.E. and MARRERO D.G.: The role of significant others in adolescent diabetes: a qualitative study. Diabtes Educ., Mar-Apr., 32 (2): , FAHMY S. and EL-SHERBINI A.F.: Determining simple parameters for social classifications for health research. Bull HIPH, 13: , ISPAD (International Society for Pediatric and Adolescent Diabetes guidelines) Cilinical practice consensus guidelines, (2009): CategoryID= INGERSOLL G.M. and MARRERO D.G.: A modified quality of life measure for youth: Psychometric properties. Dia. Educator, (17): 114-8, ABOLFOTOUH M.A., MOFIDA M. KAMAL, MOHAM- ED D. EL-BOURGY and SHERINE G. MOHAMED: Quality of life and glycemic control in adolescents with type 1 diabetes and the impact of an education intervention. In Alexandria Int. J. Gen. Med., (4): , ABOLFOTOUH M.A.: Effect of diabetes mellitus on quality of life: A review. Ann. Saudi. Med., (6): , SKINNER T.C., HOY H., MCGEE H.M. and SKOVLUND S.E.: A short form of the Diabetes Quality of Life for Youth questionnaire: exploratory and confirmatory analysis in a sample of 2,077 young people with type I diabetes mellitus. Diabetologia, 49: , HERRMANN C.: International experiences with the Hospital Anxiety and Depression Scale-a Review of validation data and clinical results-j. Psychosom Res., (42): 17-41, VINGILIS E.R., WADE T.J. and SEELEY J.S.: Predicators of adolescent self-rated health: Analysis of the National Population Health Survey. Can. J. Public. Health, (93): 193-7, NAUGHTON M.J., RUGGIERO A.M., LAWRENCE J.M., IMPERATORE G., KLINGENSMITH G.J., WAIT- ZFELDER B., et al.: Health-related quality of life of children and adolescents with type 1 or type 2 diabetes mellitus. Arch. Pediatr. Adolesc. Med. Jul., 162 (7): , LAFFEL L.M., CONNELL A., VANGSNESS L., GOEBEL-FABBRI A., MANSFIELD A. and ANDERSON B.J.: General quality of life in youth with type I diabetes: relationship to patient management and diabetes-specific family conflict. Dia. care., (26): , EMMANOUILIDOU E., GALLI-TSINOPOULOU A., KARAVATOS A. and NOUSIA-ARVANITAKIS S.: Quality of life of children and adolescents with diabetes of Northern Greek origin, Hippokratia, Jul-Sep., 12 (3): , LAFFEL L.M., VANGSNESS L. and CONNELL A.: Family focused teamwork prevented deterioration in diabetes control in children and adolescents. Evidence- Based Nurs., 7-10, LEWIN A.B., HEIDGERKEN A.D., GEFFKEN G.R., WILLIAMS L.B., STORCH E.A., GELFAND K.M., et al.: The relation between family factors and metabolic control: The role of diabetes adherence. J. ped. Psychol., (2): , GREY M., BOLAND E.A., YU C., SULLIVAN B.S. and TAMBORLANE W.V.: Personal and family factors associated with quality of life in adolescents with diabetes. Dia Care, (21): , WIEBE D.J., BERG C.A., KORBEL C., PALMER D.L., BEVERIDGE R.M. and RENN U.R.: Enhancing our understanding of adherence, metabolic control, and quality of life across adolescence. J. Pediatr Psychol., 30 (2): , AL-AKOUR N., KHADER Y.S. and SHATNAWI N.J.: Quality of life and associated factors among Jordanian
10 270 Quality of Life Among Adolescents with Type I Diabetes Mellitus in Assiut adolescents with type I diabetes mellitus. J. Diabetes Complications, Jan-Feb., 24 (1): 43-7, HOEY H., ANSTOOT H.J., CHIARELLI F., DAMME- MAN D., DANNE T., DORCHY H., et al.: Good metabolic control is associated with better QOL in 2, 101 adolescents with type I diabetes. Dia. Care., 240: , VANELLI M., CHIARELLI F., CHIARI G. and TUMINI S.: Relationship between metabolic control and quality of life in adolescents with type 1 diabetes: Report from two Italian centers for the management of diabetes in childhood. Acta. Biomed, 74 Suppl, 1: 13-7, HART H.E.: Quality of life of patients with type I diabetes. Qual life Res., (12): , ROSE M., FLIEGE H., HILDEBRANDT M., SCHIROP T. and KLOPP B.F.: The network of psychological variables. Dia. Care., (25): 35-42, BRYDEN K.S., PEVELER R.C., STEIN A., NEIL A., MAYOU R.A. and DUNGER D.: Clinical and psychological course of diabetes from adolescence to young adulthood. Dia. Care., (24): , WAGNER V.M., MULLER GODEFFROY E., VON SEN- GBUSCH S., STEFAN HAGER S. and THYEN U.: Age, metabolic control and type of insulin regime infuences health-related quality of life in children and adolescents with type 1 diabetes mellitus. Eur. J. pediatr., (8): 491-6, EISER C., FLYNN M., GREEN E., et al.: Quality of life in young adults with type I diabetes in relation to demographic and disease variables. Diabet Med., 9: , Pub. Med. 34- FAULKNER M.S.: Quality of life for adolescents with type I diabetes: parental and youth perspectives. Pediatr Nurse., 29 (5): , DELAMATER A.M.: Quality of life in youth with diabetes Diabetes Spectrum., (13): 42-46, INGERSOLL G.M., GOLDEN M.P., VANDAGRIFF J.L., MARRERO D.G. and FINEBERG N.S.: Parents of children with diabetes. What are they worried about? Dia. Educator., (18): , LAU-CHUEN Y.EN, QURESHI A.K. and SCOTT S.G.: Association between glyceamic control and quality of life in diabetes mellitus. Journal of post Graduate Medicine, (3): , 2004.