Diabetes Education in Family: Risk Factors and Barriers to Diabetes Care in Mexican Children and Adolescents


  • María del Carmen Enríquez Leal Nutrition Division, Centro de Investigación en Alimentación y Desarrollo, A.C. Sonora, Carretera a la Victoria Km.0.6 Col. La Victoria, Hermosillo, Sonora 83304, Mexico
  • María del Socorro Saucedo Tamayo Nutrition Division, Centro de Investigación en Alimentación y Desarrollo, A.C. Sonora, Carretera a la Victoria Km.0.6 Col. La Victoria, Hermosillo, Sonora 83304, Mexico
  • María Guadalupe Vidal Ochoa Department of Endocrinology, Instituto Mexicano del Seguro Social, No Reeleccion 311, Col. Centro. Cd. Obregón, Sonora 85000, México
  • Martha Nydia Ballesteros Vásquez Nutrition Division, Centro de Investigación en Alimentación y Desarrollo, A.C. Sonora, Carretera a la Victoria Km.0.6 Col. La Victoria, Hermosillo, Sonora 83304, Mexico
  • Rosa María Cabrera Pacheco Nutrition Division, Centro de Investigación en Alimentación y Desarrollo, A.C. Sonora, Carretera a la Victoria Km.0.6 Col. La Victoria, Hermosillo, Sonora 83304, Mexico
  • Cecilia Adriana Montaño Figueroa Nutrition Division, Centro de Investigación en Alimentación y Desarrollo, A.C. Sonora, Carretera a la Victoria Km.0.6 Col. La Victoria, Hermosillo, Sonora 83304, Mexico
  • María Isabel Ortega Vélez Nutrition Division, Centro de Investigación en Alimentación y Desarrollo, A.C. Sonora, Carretera a la Victoria Km.0.6 Col. La Victoria, Hermosillo, Sonora 83304, Mexico




Diabetes, Children, Metabolic control, Nutrition, Mexico


Objective: To determine barriers related to metabolic control and diabetes care in Mexican children and their families.

Design: This was a cross-sectional study designed in two stages. First stage was an assessment of risk factors for inadequate metabolic control (HbA1c higher than ADA guidelines by age group) of diabetic children using a logistic regression model. The data sources were 91 clinical files provided by public health institutions at northwest Mexico. Second stage included the design, implementation and evaluation of an educational program (EP) based on the Medical Nutrition Therapy (MNT) and the Social Cognitive Theory (SCT), accounting for critical risk factors identified previously. Twenty five children (2 to 14 years old) with type 1 diabetes and their parents agreed to participate in the EP, which promoted healthy behavioral changes regarding diet, physical activity and medical treatment over a 4-month period.

Results: Metabolic control was related to the joint effects of families low socioeconomic level and mother’s low education attainment (OR= 8.5, CI95%: 1.73, 42.16), as well as following a conventional treatment (OR= 5.0, CI95%: 1.09, 22.82). After program implementation participants’ mean glycated hemoglobin (HbA1c) decreased (9.1%±1.8% to 8.3%±2%; P=0.06). Qualitative content analysis of post-intervention interviews showed that low income, clinical inertia, and lack of social support were barriers to metabolic control of diabetes.

Conclusion and Implications: Socioeconomic, educational, and healthcare factors are related to metabolic control in Mexican children with diabetes, although educational programs based on SCT can help increase self-efficacy in patients through modeling and reinforcing activities


[1] Knip M. Etiopathogenetic aspects of type 1 diabetes. In: Chiarelli F, Dahl-Jørgensen K, Kiess W, editors. Diabetes in Childhood and Adolescence. Basel, Switzerland: Karger 2005; pp. 1-27.
[2] Armour TA, Norris SL, Jack L, Zhang X, Fisher L. The effectiveness of family interventions in people with diabetes mellitus: a systematic review. Diabet Med 2005; 22: 1295-305.
[3] Barlow J, Wright C, Sheasby J, Turner A, Hainsworth J. Self-management approaches for people with chronic conditions: a review. Patient Educ Couns 2002; 48: 177-87.
[4] Pérez Pastén E. Guía para el paciente y el educador en diabetes. Tercera ed. México, D.F.: Editorial independiente 2003.
[5] Green LW, Kreuter MW. Health promotion planning: an educational and environmental approach. 2nd ed: Mayfield 1991.
[6] Pérez-Pastén E, Pérez-Pastén P. Diseño del programa educativo. In: Pérez-Pastén E, Pérez-Pastén P, editors. Educación en diabetes Manual de apoyo.México, D.F.: Grupo Imagen Publicitario 2004; pp. 24-35.
[7] Silverstein J, Klingensmith G, Copeland K, et al. Care of children and adolescents with type 1 diabetes: a statement of the American Diabetes Association. Diabet Care 2005; 28: 186-212. http://care.diabetesjournals.org/content/28/1/186. short
[8] Enríquez-Leal MC, Montaño-Figueroa CA, Saucedo-Tamayo MS, et al. Incidencia, características clínicas y estado nutricional en niños y adolescentes mexicanos con diabetes. Interciencia 2010; 35: 455-60.
[9] Contento IR. Nutrition education: linking research, theory, and practice. Asia Pac J Clin Nutr 2008; 17(Suppl 1): 176-9.
[10] Mensing C, Boucher J, Cypress M, et al. National standards for diabetes self-management education. Task Force to Review and Revise the National Standards for Diabetes Self-Management Education Programs. Diabet Care 2000; 23: 682-9.
[11] Bandura A. Social cognitive theory of self-regulation. Organ Behav Hum Decis Process 1991; 50: 248-87.
[12] Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus: The Diabetes Control and Complications Trial Research Group. N Engl J Med 1993; 329: 977-86.
[13] National Heart, Lung, and Blood Institute. Obesity education initiative expert panel on the identification, evaluation and treatment of overweight and obesity in adults. NIH publication No. 98-4083: 1998.
[14] WHO/NUT/NCD, Obesity. Preventing and managing the global epidemic. World Health Organization, Division of non-communicable disease and programme of nutrition family and reproductive health. Report of a WHO Consultation Obesity. Geneva 1998.
[15] Allain CC, Poon LS, Chan CS, Richmond W, Fu PC. Enzymatic determination of total serum cholesterol. Clin Chem 1974; 20: 470-5.
[16] Carr TP, Andresen CJ, Rudel LL. Enzymatic determination of triglyceride, free cholesterol, and total cholesterol in tissue lipid extracts. Clin Biochem 1993; 26: 39-42.
[17] Warnick GR, Benderson J, Albers JJ. Dextran sulfate-Mg2+ precipitation procedure for quantitation of high-density-lipoprotein cholesterol. Clin Chem 1982; 28: 1379-88.
[18] Friedewald WT, Levy RI, Fredrickson DS. Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge. Clin Chem 1972; 18: 499-502.
[19] Karl J, Burns G, Engel W, et al. Development and standardization of a new immunoturbidimetric HbA1c assay. Klin Lab 1993; pp. 991-6.
[20] Bakkeren D, Bonvicini P, Buxeda M, et al. Multicenter evaluation of an improved immunoturbidimetric assay for the determination of HbA1c on clinical chemistry analyzers. Clin Lab 1999; 45: 123-37.
[21] Conway JM, Ingwersen LA, Vinyard BT, Moshfegh AJ. Effectiveness of the US Department of Agriculture 5-step multiple-pass method in assessing food intake in obese and nonobese women. Am J Clin Nutr 2003; 77: 1171-8.
[22] Ortega M, Quizán P, Morales G, Preciado M. Cálculo de ingestión dietaria y coeficientes de adecuación a partir de: registro de 24 horas y frecuencia de consumo de alimentos. Cuadernos de trabajo 1999; (1).
[23] Geghardt S, Matthews R. Nutritive Value of Foods. USDA. Home and Garden Bulletin Washington, DC. 1981; 72: 1-72.
[24] Instituto Nacional de la Nutrición Salvador Zubirán. Subdirección de nutrición experimental y ciencia de los alimentos. Tablas de composición de alimentos. México 1980; 1-248.
[25] López-Alvarenga JC, Reyes-Díaz S, Castillo-Martínez L, Dávalos-Ibáñez A, González-Barranco J. Reproducibilidad y sensibilidad de un cuestionario de actividad física en población mexicana. Salud Pública de México 2001; 43: 306-12.
[26] Patton MQ. Qualitative research and evaluation methods. 3rd ed. Thousand Oaks, CA: Sage 2002.
[27] American Academy of Pediatrics. National cholesterol education program: report of the expert panel on blood cholesterol levels in children and adolescents. Pediatrics 1992; 89: 525-84.
[28] Phillips LS, Branch JWT, Cook CB, et al. Clinical Inertia. Ann Intern Med 2001; 135: 825-34.
[29] Thompson SJ, Auslander WF, White NH. Comparison of single-mother and two-parent families on metabolic control of children with diabetes. Diabet Care 2001; 24: 234-8. http://care.diabetesjournals.org/content/24/2/234
[30] Araujo MB, Mazza CS. Assessment of risk factors of poor metabolic control in type 1 diabetic children assisted in a public hospital in Argentina. Pediatr Diabetes 2008; 9: 480-7.
[31] Johns C, Faulkner MS, Quinn L. Characteristics of adolescents with type 1 diabetes who exhibit adverse outcomes. Diabetes Educ 2008; 34: 874-85.
[32] Bandura A. Health promotion from the perspective of social cognitive theory. Psychol Health 1998; 13: 623-49.
[33] Albarran NB, Ballesteros MN, Morales GG, Ortega MI. Dietary behavior and type 2 diabetes care. Patient Educ Couns 2006; 61: 191-9.
[34] Hood KK, Butler DA, Volkening LK, Anderson BJ, Laffel LM. The blood glucose monitoring communication questionnaire an instrument to measure affect specific to blood glucose monitoring. Diabetes Care 2004; 27: 2610-5.
[35] Daneman D. State of the world’s children with diabetes. Pediatr Diabetes 2009; 10: 120-6.
[36] Ballesteros MN, Cabrera RM, Saucedo MS, Aggarwal D, Shachter NS, Fernandez ML. High intake of saturated fat and early occurrence of specific biomarkers may explain the prevalence of chronic disease in northern mexico. J Nutr 2005; 135: 70.
[37] Lemieux I, Lamarche B, Couillard C, et al. Total cholesterol/HDL cholesterol ratio vs LDL cholesterol/HDL cholesterol ratio as indices of ischemic heart disease risk in men: the Quebec Cardiovascular Study. Arch Intern Med 2001; 161: 2685-92.
[38] Helgeson VS, Viccaro L, Becker D, Escobar O, Siminerio L. Diet of adolescents with and without diabetes: trading candy for potato chips? Diabetes Care 2006; 29: 982-7.
[39] Ortega M, Valencia M. Measuring the intakes of foods and nutrients of marginal populations in north-west Mexico. Public Health Nutr 2002; 5: 907-10.
[40] Franz MJ, Bantle JP, Beebe CA, et al. Evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications. Diabetes Care 2002; 25: 148-98.
[41] Patton SR, Dolan LM, Powers SW. Mealtime interactions relate to dietary adherence and glycemic control in young children with type 1 diabetes. Diabetes Care 2006; 29: 1002-6.

[42] Lustman PJ, Anderson RJ, Freedland KE, De Groot M, Carney RM, Clouse RE. Depression and poor glycemic control: a meta-analytic review of the literature. Diabetes Care 2000; 23: 934-42.
[43] Bandura A. Health promotion by social cognitive means. Health Educ Behav 2004; 31: 143-64.






General Articles