NURSING

PRACTICE &
SKILL

Patient Education: Teaching the Adult with Diabetes

Mellitus, Type 1
What is Patient Teaching for the Adult with Diabetes Mellitus,
Type 1?

ICD-9
250.1

ICD-10
E10

Author
Zeena Engelke, RN, MS
Cinahl Information Systems, Glendale, CA

Reviewers
Sara Richards, MSN, RN
Cinahl Information Systems, Glendale, CA

Diabetes mellitus, type 1 (DM1; formerly known as insulin-dependent or juvenile

diabetes) is a metabolic disorder characterized by glucose dysregulation due to beta
cell dysfunction leading to severe insulin deficiency. Treatment requires strict glycemic
control through use of insulin, diet, and exercise (For information, see Quick Lesson
About Diabetes Mellitus, Type 1 )
What: Patient education for adults with DM1 is the process of providing information to
the patient and patients family to improve their knowledge of DM1, improve self-care
skills, and enhance their abilities to cope with chronic illness. Patient education of adults
with DM1 involves a teaching and learning process regarding early diagnosis, treatment,
self-management, and management of diabetes-related complications
How: A variety of learning and motivational activities (e.g., direct instruction, telephone
communications, written materials, email, Internet and other computer-mediatedoptions,
DVD/video and audio recordings, support groups, demonstrations and return
demonstrations, self-help groups) can be utilized to support the patient in learning
Where: Patient education for adult patients with DM1 is usually provided in an
outpatient clinician office or in the hospital setting, including in the emergency
department
Who: Diabetes education should be provided by healthcare professionals (e.g., certified
diabetes educators, nurses, physicians) and should not be delegated to assistive clinical
staff

What is the Desired Outcome When Teaching an Adult with

Diabetes Mellitus, Type 1?
Effective diabetes education can empower adults with DM1 and allow them to
better understand DM1 and how it affects their overall health
adhere to self-care skills and health practices that promote strict glycemic control (e.g.,
self-monitoring of blood glucose levels, subcutaneous insulin administration [Figure 2]
[Figure 3], insulin pump therapy)

Darlene Strayer, RN, MBA

Cinahl Information Systems, Glendale, CA
Nursing Practice Council
Glendale Adventist Medical Center,
Glendale, CA

Editor
Diane Pravikoff, RN, PhD, FAAN
Cinahl Information Systems, Glendale, CA

December 26, 2014

Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright2014, Cinahl Information Systems. All rights
reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by
any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice
or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare
professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206

Figure 2: The capillaries are located in the dermis. Copyright Madhero88, 2011.
Licensed under Creative Commons Attribution-Share Alike 3.0 Unported License

Figure 3: Preferred sites for subcutaneous injection in adults and children. Copyright 2014, EBSCO Information Services.

consider the risks and benefits of diagnostic tests (e.g., HbA1c monitoring) and treatment options (e.g., islet cell
transplantation) and participate in shared decision making
employ effective strategies for managing symptoms (e.g., of hypo- and hyperglycemia)
initiate and maintain lifestyle changes (e.g., healthy eating, appropriate exercise, frequent clinician surveillance) to prevent
complications (e.g., ketoacidosis, severe hypoglycemic reactions, and chronic complications such as cardiovascular
disease, stroke, end-stage kidney disease, blindness, and gangrene of the limbs)
cope with the psychosocial and emotional aspects of living with a chronic illness

 experience improved health outcomes (e.g., good glycemic control, reduced need for medications, decreased development
of severe diabetes-related complications)

Why is Teaching an Adult with Diabetes Mellitus, Type 1 Important?

Diabetes education provides the adult with DM1 a clearer understanding of the diagnosis, treatment option risks and
benefits, the importance of strict glycemic control, strategies for preventing diabetes-related complications, and how to
become more involved in diabetes self-care and in making decisions about diabetes care and treatment. Diabetes education
helps persons with DM1 to achieve glycemic targets and prevent or delay complications
Patient education is required by The Joint Commission (TJC). In 2004, TJC integrated the required patient education
elements and standards throughout their accreditation manual instead of in a designated chapter (TJC, 2014)

Facts and Figures

17.9 million persons in the United States have been diagnosed with diabetes, and 5.7 million others likely have undiagnosed
diabetes; 7.8% of the total U.S. population have elevated glucose levels, which is suggestive of prediabetes and increased
risk of developing diabetes. DM1 accounts for approximately 510% of all persons with diabetes (AADE, 2014)
Intensive treatment (e.g., 34 insulin injections/day) for DM1 is important to prevent acute diabetes-related complications
and prevent or delay chronic microvascular and macrovascular complications. Intensive treatment has been shown to
decrease risk of retinopathy, nephropathy, and neuropathy by 70%, 54%, and 64%, respectively (Gaddam et al., 2014)

What You Need to Know Before Teaching an Adult about Diabetes Mellitus, Type 1
The American Diabetes Association defines diabetes mellitus as having a fasting plasma glucose 126 mg/dL on two
separate occasions, the presence of signs and symptoms of hyperglycemia (e.g., polyuria, polydipsia, and weight loss) or of
hyperglycemic crisis with a random plasma glucose > 200 mg/dL, an oral glucose tolerance test 200 mg/dL, or an HbA1c
reading of 6.5%. (DynaMed, 2014; Gaddam et al., 2014)
DM1 is characterized by severe insulin deficiency resulting from autoimmune destruction of insulin-producing pancreatic
-cells.Patients with DM1 should be taught that when there is a lack of insulin, the following can occur:
Cells are unable to use glucose for metabolism. More specifically, glucose is unable to enter the cells and accumulates in
the bloodstream, causing high blood glucose levels (i.e., hyperglycemia)
The kidneys are not able to reabsorb high levels of glucose and glucose appears in urine (i.e., glycosuria). As the excess
glucose is excreted in the urine, large volumes of water are excreted with it (i.e., polyuria) and the patient experiences
severe thirst (i.e., polydipsia)
When cell glucose requirements are unmet, increased levels of glucagon and other stress hormones are released inan
attempt to increase glucose availability, and blood glucose levels rise even higher
Although the patient can have increased appetite (i.e., polyphagia), weight loss occurs because body fat and protein stores
are depleted
Without insulin, fat cells break down and spill ketones in the urine (i.e., ketonuria)
Without treatment, the patient develops nausea, vomiting, abdominal pain, and ultimately life-threatening coma or death
A target HbA1c of 7% or less is recommended for adults with DM1. Patient education combined with continuous blood
glucose monitoring and continuous subcutaneous insulin infusion is recommended to achieve this target
Patients in Switzerland were best able to maintain strict glycemic control and resolve typical problems of diabetes care
when they met every 3 months face-to-face with the same physician, who was experienced in flexible intensified insulin
therapy. During patient meetings with the physician, a detailed analysis of blood glucose results was conducted using the
patients log book and specialized software that assessed for repetitive patterns. The importance of performing at least 4
glucose measurements daily and avoiding hypoglycemic episodes was emphasized in patient education. Patient education
included providing information on the effects of meal choices and physical activity on blood glucose readings and insulin
requirements. In this 5-year study of outpatients, a median HbA1c of < 7.1% was achieved (compared with a median of
8% that is typically achieved) and few severe hypoglycemic events were reported. HbA1c levels tended to be lower in
nonsmokers, persons without mental health conditions, and men. HbA1c levels were the same for insulin pump users as
for persons who performed multiple daily injections. Patients enrolled in the study demonstrated a high rate of adherence;
85.2% did not miss any appointments, and 7.6% missed only one appointment (Albrecht et al., 2011)
Results of the Diabetes Control and Complications Trial (DCCT; i.e., a study conducted by the National Institute of Diabetes
and Digestive and Kidney Diseases) and the United Kingdom Prospective Diabetes Study underscore the need for aggressive
management of diabetes to prevent severe complications. Control of blood glucose, blood pressure, and blood lipid levels are
the three most important factors in preventing complications of DM1 (AADE, 2014)

 DM1 can lead to chronic hyperglycemia, systemic acid-base imbalance, insufficient glucose delivery to the brain and
retina, inadequate blood supply to the tissues, widespread vascular degeneration, and neuropathy
Inpatient diabetes education should focus on the following:
Information regarding care and treatment during the hospital stay (e.g., rationale for inpatient glycemic control, glycemic
targets, basal-bolus insulin therapy, and acute complications such as diabetic ketoacidosis [DKA] and hyperosmolar
hyperglycemic nonketotic syndrome [HHNS])
Learning how to self-perform certain skills (i.e., carbohydrate selection and counting, blood glucose monitoring, treatment
of hypoglycemia, safe medication administration)
The focus of outpatient diabetes education should be on self-carebehaviors
The American Association of Diabetes Educators (AADE) recommends emphasis on educational information regarding
healthy eating, staying active, monitoring status, taking medication, problem-solving, reducing risk, and healthy strategies
for coping. (For details, see http://www.diabeteseducator.org/ProfessionalResources/AADE7/)
Additional topics that are appropriate to education of adults with DM1 include participation in sporting events and
celebratory activities, becoming pregnant when having DM1. (For information, see Nursing Practice & Skill: Patient
Education Teaching the Pregnant Patient with Diabetes Mellitus, Type 1 ), and pancreatic islet transplantation and other
innovative treatment options
Diabetes educators acknowledge that teaching diabetes self-management to inpatients is challenging, and recommend
focusing on what is referred to as survival skills, including the following (AADE, 2014):
The importance of identifying a care provider to continue assisting the patient with diabetes care after discharge
Self-monitoring of DM1-related signs and symptoms, including blood glucose levels
Ability to recognize hyper- and hypoglycemia and knowledge of strategies for treatment and prevention
Healthy nutrition and the benefits of establishing consistent eating patterns
When and how to take medication that lowers blood glucose
Sick-day management
Proper use and disposal of needles and syringes
A variety of DM1 teaching/learning strategies have been tried and tested. Below is a sample of findings from recent studies:
A 6-week course of 50-minute, one-to-one counseling sessions using a patient-centered, nonjudgmental approach in which
patients with DM1 were encouraged to talk freely about their anxieties and fears was associated with better glycemic
control and reduced anxiety, and was considered to be an effective intervention in helping patients to self-manage their
diabetes (Masding et al., 2011)
In France, a flexible intensive therapy program was used to provide the same content to patients in 3 groups that wereeach
focused on a different issue: decreasing HbA1c concentration, improving quality of life and satisfaction with treatment, and
decreasing frequency of hypoglycemic episodes. By using a patient-centered approach, clinicians were able to successfully
provide consistent information and achieve individual therapeutic targets for each patient (Halbron et al., 2014)
In a large, multi site study of youth with DM1 in the U.S., researchers noted that survival skills were consistently
covered during patient education sessions, but there were frequent gaps in topics such as nutritional therapy. Researchers
emphasized the need for multidisciplinary healthcare professionals to collaborate to improve these educational deficits and
improve patient outcomes (Jaacks et al., 2014)
In a study of 406 young adults with DM1, researchers noted that individuals with DM1 often experience high levels of
distress. They cautioned that psychosocial interventions should not only focus on resolving anxiety and depression, they
should also include information and discussion about predictable emotional reactions to illness such as fear and sadness,
factors which are likely to interfere with self-management (Zoffmann et al., 2014)
Authors of a study of 238 children reported that the site of the initial diabetes education does not affect metabolic outcomes
and is not associated with concerns regarding safety. Families of medically stable children with new-onset DM1 were
successfully and safely educated in an outpatient clinic setting rather than requiring a hospital admission. After 1 year,
21.8% of the children who were educated in the outpatient setting were on insulin pump therapy compared with 14.7%
of the children who required an inpatient admission for education and 2.7% who received a combination of inpatient and
outpatient education (Tonyushkina et al., 2014)
Every effort should be made to promote the delivery of consistent diabetes education throughout the course of patient care
Redundancy and conflicting information should be minimized to reduce frustration and confusion as patients navigate the
healthcare system (e.g., from the emergency department to an inpatient unit, ambulatory diabetes specialty clinic, or nutrition
clinic)

 The most effective educators of persons with DM1 are those who tailor information to specifically address the learning needs
of the patient. The Scope of Practice for Diabetes Educators clearly delineates that instruction should be individualized to
account for patient age, cultural preferences, health beliefs, and preferred learning style (AADE, 2014)
When clinically appropriate, it may be beneficial to teach others (e.g., spouses/partners, family members, co-workers, close
friends) about potentially emergent conditions (e.g., severe hypoglycemia, DKA, HHNS) related to DM1 and how to assist if
the patient is unable to respond appropriately
The most successful strategies for teaching adults with DM1 are individualized educational interventions
Patient education and teaching tools (e.g., handouts, books, DVDs) about DM1 should be tailored to address the patients
specific needs and priorities and should be age- and developmentally-appropriate
Visually oriented informational handouts (i.e., those with diagrams and limited wording) should be patient-friendly and
easy to read
All teaching should be patient-centered and evidence-based
Educational information should be delivered in a cultural-sensitivemanner and in a language and at a level that can be
easily understood by the patient
Professional certified medical interpreters, either in person or via telephone, should be used when there are language
barriers
Simple, nonmedical language should be used for all patients, especially when low literacy levels are assessed
Preliminary steps that should be performed before teaching adult patients about DM1 include the following:
Review facility protocols and policies about teaching adult patients about DM1
Become familiar with facility- and unit-specific practices for teaching adult patients about DM1
Identify acceptable DM1 resources that are available on site or online
Verify availability of necessary supplies prior to initiating the educational session, including
a teaching guideline or documentation form outlining key content areas such as the need for strict glycemic control to
prevent diabetes-related complications; diet, exercise, and insulin therapy strategies; and regular clinician surveillance
corresponding written materials, including key points about safety precautions (e.g., glycemic targets, sick day guidelines,
severe hypoglycemia, ketoacidosis)
a glucagon kit, a blood glucose monitoring device designed for use at home, test strips, lancets, soap, and water
information about Internet and community resources that are available to assist patients in learning about DM1
information on how to contact members of the healthcare team for questions or concerns

How to Teach an Adult about Diabetes Mellitus, Type 1

Assess the patient for
readiness to learn
Particularly during acute phases of treatment, patients with DM1 and their family members may be at different stages of
readiness; it is important to individualize your approach based on each learners readiness
preferred learning style
Individuals are auditory, visual, or tactile learners, and learn by hearing (e.g., listening to other persons talk about their
experiences of handling long-term complications of DM1), by seeing (e.g., observing a nurse demonstrate how to inject
glucagon for severe hypoglycemia), and by doing (e.g., demonstrating how to properly use a pump to deliver insulin)
patient- and family-identified learning priorities
When there is incongruence between the patient/family priorities and the healthcare providers goals, all will need to
explore why the incongruence exists
learning barriers
Barriers may include cognitive issues; learning disabilities; physical limitations; language; low literacy; impaired hearing,
sight, and/or speech; financial issues; and cultural, psychosocial, and/or emotional concerns
- Patients with long-term complications of DM1 should be assessed for visual impairment and the need for large print
materials and adaptive aids (e.g., talking glucose monitors, syringe magnifiers for drawing up insulin)
learning needs and desires
Many patients and family members are preoccupied with the diabetes diagnosis and are so overwhelmed with the
complexity of their care that they need coaching to better understand what their educational needs are
- This may be especially true when patients undergo major treatment (e.g., islet transplantation) or when a patients
condition is complicated by ketoacidosis, renal disease, or cardiovascular complications

 Plan for timely delivery of relevant information

The overall plan should be comprehensive, but divisible into smaller segments of information to avoid overwhelming the
patient and family
High quality teaching tools that support teaching/learning should be identified in advance
Family involvement is important and teaching should occur when the primary caregivers and other support persons are
available
Implement the patient education plan
Anticipate a planned approach to teaching/learning, yet be prepared to be flexible and individualize information based on
the patients needs and desires. Interventions that are tailored to the individual patient are most effective
With the patient and family, set mutually achievable goals for learning
Provide timely and relevant information, including the following:
Review basic DM1 information as needed. Initial and reinforced topics can include what DM1 is, the importance of
metabolic control (e.g., blood glucose self-monitoring;managing hyper- and hypoglycemia and episodes of ketoacidosis),
insulin therapy (e.g., self-injectiontechniques, site rotation, dose adjustments, types of insulin and their action times,
basal-bolus therapy, pump management), healthy eating (e.g., food choices, reading food labels, carbohydrate selection
and counting), physical exercise and activity, sick day guidelines, prevention of complications (e.g., the importance of
routine clinician surveillance and laboratory testing), and the emotional and psychosocial aspects of living with diabetes
and chronic illness
When the patient is first diagnosed with DM1, education should focus on only the most important information to avoid
overwhelming the patient. If the patient is unable to perform necessary self-care skills, family members or home care staff
may be helpful in supporting the patient temporarily
When the patient and family appear ready to learn, introduce a more comprehensive program of education that
emphasizes the performance of self-care behaviors. Adults who have lived with DM1 for many years should be
serially assessed for adherence and provided with pertinent information to maximize diabetes self-management and/or
information about new findings and technologies related to DM1
- Although patients are motivated by the selection of a blood glucose target, when the target is difficult to attain or
maintain some patients adapt and personalize the target. Patients should be educated that doing this can negatively affect
glycemic control (Rankin et al., 2012)
Educate the patient regarding his/her current HbA1c level and review strategies for maintaining strict metabolic control
through diet, exercise, and insulin therapy
- HgA1C targets should be individualized according to the patients personal and clinical situation (e.g., a motivated,
newly-diagnosed person with DM1 would have a different target than an older patient who has limited life expectancy
and increased risk of hypoglycemia)
As treatment continues, problem-solve with the patient, including educating and encouraging discussion of strategies to
decrease risk of complications, particularly complications related to glycemic control, blood pressure, and lipid levels.
Provide education in a positive, reassuring manner and focus on strategies for best achieving strict glycemic control.
Before DM1 progresses to severe complications, educate patients regarding the consequences of poor glycemic control
and encourage them to do their best to consistently achieve good glycemic control
If severe complications develop and hospitalization is required, emphasize information regarding survival skills that is
specifically related to the hospital stay. As needed, educate patient and family of the need for more intensive treatments
(e.g., dialysis, transplantation, amputation)
Educate and encourage discussion of patient-specificemotional and psychosocial aspects of living with DM1
Capture teachable moments during the provision of clinical care (e.g., if patient is hospitalized following a motor vehicle
accident due to experiencing a blackout, educate regarding strategies for strict glycemic control and how to prevent
recurrence of blackouts while driving)
Provide choices in learning (e.g., who the patient wishes to have present for the teaching session, what information to cover
first) and in making decisions about treatment options. When teaching adults, be aware of situations that may warrant
having a private conversation (e.g., sexuality and reproductive issues related to diabetes) with the patient that does not
include family members
Use a variety of teaching/learning strategies for best results
Providing opportunities to practice self-care skills is important
- Make the learning experience as home-like and realistic as possible
- Allow sufficient time for the patient to make mistakes and be able to try again within a safe and supportive environment

- Integrate what if questions to guide the patient through potential problem-solving situations (e.g., what if you need
to fast before having surgery, what if you leave the insulin in a cold car overnight, what if you work the night shift and
need to adjust your insulin schedule)
Internet resources are readily available to most diabetes patients today, although healthcare professionals disagree as to
the value of Internet information. One strategy that may enhance Internet usage is to provide patients with a list of Web
sites that contain information that is accurate, current, and understandable. Patient and professional resources can be
found at http://www.diabetes.org/and http://www.diabeteseducator.org/DiabetesEducation/Patient_Resources/
Evaluate the patient/family response to education regarding DM1
Serially assess learning throughout the course of patient care
Use a teach-back method to evaluate learner understanding
Have the patient restate health information and/or perform a return demonstration of a self-care skill, allowing the nurse
to listen, observe carefully, and clarify, as needed
Remember that specific information is better recalled than general information
Use a self-efficacy rating (i.e., the extent to which a person believes he or she is capable of achieving a desired outcome) to
evaluate how confident the learner is of understanding information or performing a skill (e.g., ask On a scale of 110, how
certain are you that you will be able to follow the sick day guidelines and safely adjust your insulin?)
If the patients response is < 7, the plan will need to be readjusted (e.g., reteach until the patients response is 7, further
involve family or other caregivers in teaching, arrange for home care to support the patient and family until desired result
is met)
Communicate any concerns with members of the multidisciplinary healthcare team so that information can be reinforced and
the learning plan can be continued or modified accordingly. Document the following information in the patients medical
record:
All education provided about DM1, including specific teaching/learning strategies implemented
Assessment findings regarding readiness to learn, preferred learning style(s), learning needs/desires, and learning priorities
of the patient
Identified barriers to learning and methods used to help overcome these barriers
Patient response to learning, including demonstrated level of understanding and/or ability to perform necessary skills
Plan for continuation of patient education, including whether or not specific information should be reinforced or taught
again using a different teaching method

What to Expect After Teaching an Adult with Diabetes Mellitus, Type 1

Adults with DM1 will
better understand DM1 and how it affects their overall health
adhere to self-care skills and health practices that promote strict glycemic control
understand the risks and benefits of diagnostic tests and treatment options, and participate in shared decision making
employ effective strategies for managing DM1-related symptoms
engage in lifestyle changes to prevent complications
effectively cope with the psychosocial and emotional aspects of living with a chronic illness
experience improved health outcomes
receive the delivery of consistent educational information throughout the course of patient care
perceive that they have received information in a culturally sensitive manner in a language and level that is understandable

Red Flags
Adults with DM1 must be taught about proper disposal of needles and the impact of this practice on public safety
Unless supported by the patient, the use of family members, friends, or nonprofessional staff as interpreters is a violation of
the patients right to confidentiality; use of nonprofessional staff is also a violation of the patients right to confidentiality;
these staff members are often part of the patients home community
At this time, scientific studies do not support the use of tall man letters (i.e., the inclusion of uppercase letters within drug
names to distinguish them from other medications that have similar spelling and/or pronunciation) when presenting drug
names to patients (ISMP, 2011)

What Do I Need to Tell the Patient/Patients Family?

Based on their needs and desires, educate patients and their family members about DM1, treatment option risks and benefits,
self-care skills, and coping with chronic illness, including preventing and managing diabetes-relatedcomplications

References
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Medicine, 28(5), 539-542. doi:10.1111/j.1464-5491.2011.03260.x
2. American Association of Diabetes Educators (AADE). (2014). Practice documents. Retrieved October 14, 2014, from http://www.diabeteseducator.org/ProfessionalResources/
position/
3. American Diabetes Association. (2013). Standards of medical care in diabetes-2013. Diabetes Care, 36(Suppl 1), S11-S66. doi:10.2337/dc13-S011
4. American Diabetes Association (ADA). (2013). Diagnosis and classification of diabetes mellitus. Diabetes Care, 37(Suppl 1), S81-S90. doi:10.2337/dc14-S081
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Elsevier.
7. Haas, L., Maryniuk, M., Beck, J., Cox, C. E., Duker, P., Edwards, L., & Youssef, G. (2013). National standards for diabetes self-management education and support. Diabetes
Care, 36(Supp 1), S100-S108. doi:10.2337/dc12-1707
8. Halbron, M., Sachon, C., Simon, D., Obadia, T., Grimaldi, A., & Hartemann, A. (2014). Evaluation of a 5-day education programme in type 1 diabetes: Achieving individual
targets with a patient-centred approach. Diabetic Medicine, 31(4), 500-503. doi:10.1111/dme.12372
9. Institute for Safe Medication Practices (ISMP). (2011). FDA and ISMP lists of look-alike drug names with recommended tall man letters. Retrieved October 14, 2014, from http://
www.ismp.org/Tools/tallmanletters.pdf
10. Jaacks, L. M., Bell, R. A., Dabelea, D., D'Agostino, R. B., Dolan, L. M., Imeratore, G., ... Mayer-Davis, E. J. (2014). Diabetes self-management education patterns in the US
population-based cohort of youth with type 1 diabetes. Diabetes Educator, 40(1), 29-39. doi:10.1177/0145721713512156
11. The Joint Commission. (2014). Comprehensive accreditation manual for hospitals (CAMH): The official handbook. Oakbrook Terrace, IL: Joint Commission Resources, Inc.
12. Masding, M. G., Ashley, K., & Klejdys, S. (2011). Introduction of a counselling service for patients with type 1 diabetes: Better glycaemic control and reduced anxiety. Practical
Diabetes International, 28(1), 28-30. doi:10.1002/pdi.1548
13. Rankin, D., Cooke, D. D., Heller, S., Elliot, J., Amiel, S., & Lawton, J. (2012). Experiences of using blood glucose targets when following an intensive insulin regimen: A
qualitative longitudinal investigation involving patients with type 1 diabetes. Diabetic Medicine, 29(8), 1079-1084. doi:10.1111/j.1464-5491.2012.03670.x
14. Tonyushkina, K. N., Visintainer, P. F., Jasinski, C. F., Wadzinski, T. L., & Allen, H. F. (2014). Site of initial diabetes education does not affect metabolic outcomes in children
with T1DM. Pediatric Diabetes, 15(2), 135-141. doi:10.1111/pedi.12069
15. Zoffmann, V., Vistisen, D., & Due-Christiansen, M. (2014). A cross-sectional study of glycemic control, complications and psychosocial functioning among 18- to 35-year old
adults with type 1 diabetes. Diabetic Medicine, 31(4), 493-499. doi:10.1111/dme.12363