Problem solving has been identified as a skill necessary for effective diabetes self-management (1) and as a training paradigm incorporated into diabetes education (2,3). However, relatively little has been reported about problem-solving skills among patients with diabetes. Self-management models describe steps in the problem-solving process that rely on reasoning, conceptualization, planning, mental flexibility, and sequencing/ability to proceed in an ordered fashion. In this study, a sample of adults with type 1 diabetes was examined to assess 1) performance on neuropsychological measures of problem solving and related skills relative to normative data and 2) the association between metabolic control and problem solving.

A total of 23 adults with type 1 diabetes (ages 18–45 years, 78% with 13–18+ years education) were administered the Comprehension, Similarities, Block Design, and Picture Arrangement subtests from the Wechsler Adult Intelligence Scale-Revised (WAIS-R), the Trail Making Test Part B (Trails B), the Wisconsin Card Sorting Test (WCST), and the Porteus Maze Test (PMT). Disease variables investigated were disease duration (mean 13.4 ± 7.9 years); number of episodes of severe hypoglycemia requiring help, including hospitalization and coma (mean 2.6 ± 2.9); number of episodes of severe hyperglycemia, including hospitalizations, ketoacidosis, and coma (mean 1.2 ± 1.6); hypoglycemic coma duration (mean 17.9 ± 37.9 min); hyperglycemic coma duration (mean 2.8 ± 7.8 h); and HbA1c (n = 17, mean 8.0 ± 1.3%). The mean blood glucose level at the time of testing was 201 ± 81 mg/dl.

Individual performance on problem-solving measures was unimpaired relative to adjusted (age, sex, education) normative data (4,5,6,7). Significant Pearson’s and partial correlations were found with inverse relationships between severe hypoglycemia and both block design (r = −0.69, P < 0.001) and Trails B (r = −0.50, P = 0.01) performance; between severe hyperglycemia and picture arrangement (r = −0.51, P = 0.01); and between HbA1c and both PMT (r = −0.50, P < 0.05) and WCST loss of set after five consecutive correct sortings (r = 0.58, P < 0.05). A Pearson’s correlation between severe hyperglycemia and WCST categories (r = −0.42, P = 0.05) approached significance. Glucose at time of testing, disease duration, and coma duration were not significantly related to test scores.

Complex thinking and problem solving have been reported as significant challenges in diabetes education (8). Our findings suggest that problem-solving skills may be differentially associated with metabolic control. We observed that history of severe hypoglycemia was associated with reduced performance on timed tasks that required visuospatial skills, which may reflect a slowed and deliberate pattern of problem solving (9). In contrast, history of severe hyperglycemia and recent metabolic control were associated with social reasoning, planning, and complex problem solving, all of which are required for real-world application of decision making in diabetes self-management. Deficits in these skills, relative to normal control subjects, have been reported in various diabetes populations (10,11). Results need to be replicated in large-scale prospective studies in which consistent measures of problem-solving skills (neuropsychological and applied) are investigated.

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Address correspondence to Felicia Hill-Briggs, Department of Physical Medicine and Rehabilitation, Johns Hopkins SOM, Good Samaritan POB Suite 406, 5601 Loch Raven Blvd., Baltimore, MD 21239. E-mail: