As a licensed clinical psychologist working in diabetes and Cystic Fibrosis clinics for the past 10 years, Dr. Naranjo focuses on the psychosocial needs of patients and families with diabetes and CF. Through clinical research, she aims to understand barriers and facilitators to diabetes self-management, how families and individuals with diabetes respond to health technology, and how to best provide services that engage youth and their families. She is a member of the Stanford Diabetes Research Center.
Clinical Professor, Pediatrics - Endocrinology and Diabetes
Clinical Associate Professor, Psychiatry and Behavioral Sciences - Child and Adolescent Psychiatry
Member, Stanford Diabetes Research Center (2016 - Present)
Boards, Advisory Committees, Professional Organizations
Publication & Presentation Committee Member, Cystic Fibrosis Foundation's Success with Therapies Research Consortium (2015 - Present)
Clinical Advisory Committee, College Diabetes Network (2014 - Present)
Diabetes Health Sense Task Group Member, National Diabetes Education Program (2013 - Present)
Advisory Board Member, CarbDM (2013 - Present)
PhD Training: Arizona State University (2009) AZ
Fellowship: UCSF Psychiatry Residency (2011) CA
Internship: Boston Children's Hospital (2009) MA
Diabetes Device Use in Adults With Type 1 Diabetes: Barriers to Uptake and Potential Intervention Targets.
2017; 40 (2): 181-187
Diabetes devices (insulin pumps, continuous glucose monitors [CGMs]) are associated with benefits for glycemic control, yet uptake of these devices continues to be low. Some barriers to device uptake may be modifiable through psychosocial intervention, but little is known about which barriers and which patients to target.We surveyed 1,503 adult T1D Exchange participants (mean age 35.3 [SD 14.8] years, mean diagnosis duration 20.4 [SD 12.5] years) to investigate barriers to device uptake, understand profiles of device users versus nonusers, and explore differences by age and sex. Scales used were the Diabetes Distress Scale, Technology Use Attitudes (General and Diabetes-Specific), and Barriers to Device Use and Reasons for Discontinuing Devices.Most commonly endorsed modifiable barriers were related to the hassle of wearing devices (47%) and disliking devices on one's body (35%). CGM users (37%) were older than nonusers (mean 38.3 vs. 33.5 years), had diabetes for longer (22.9 vs. 18.8 years), had more positive technology attitudes (22.6-26.0 vs. 21.4-24.8), and reported fewer barriers to using diabetes technology than nonusers (3.3 vs. 4.3). The youngest age-group (18-25 years) had the lowest CGM (26% vs. 40-48%) and insulin pump (64% vs. 69-77%) uptake, highest diabetes distress (2.2 vs. 1.8-2.1), and highest HbA1c levels (8.3% [67 mmol/mol] vs. 7.2-7.4% [55-57 mmol/mol]).Efforts to increase device use need to target physical barriers to wearing devices. Because young adults had the lowest device uptake rates, highest distress, and highest HbA1c compared with older age-groups, they should be the focus of future interventions to increase device use.
View details for DOI 10.2337/dc16-1536
View details for PubMedID 27899489
Fear of Hypoglycemia in Children and Adolescents and Their Parents with Type 1 Diabetes.
Current diabetes reports
2016; 16 (8): 77-?
Hypoglycemia is a frequent occurrence in children and adolescents with type 1 diabetes. A variety of efforts have been made to standardize the definition of hypoglycemia and to define one of its most significant psychosocial consequences-fear of hypoglycemia (FOH). In addition to documenting the experience of FOH in children and adolescents type 1 diabetes and their parents, studies have investigated the relations between FOH and glycemic control and diabetes technology use. This review provides a summary of the recent FOH literature as it applies to pediatric type 1 diabetes.
View details for DOI 10.1007/s11892-016-0762-2
View details for PubMedID 27370530
Diabetes Technology: Uptake, Outcomes, Barriers, and the Intersection With Distress.
Journal of diabetes science and technology
2016; 10 (4): 852-858
Patients managing type 1 diabetes have access to new technologies to assist in management. This manuscript has two aims: 1) to briefly review the literature on diabetes technology use and how this relates to psychological factors and 2) to present an example of human factors research using our data to examine psychological factors associated with technology use. Device/technology uptake and use has increased over the years and at present day is a common clinical practice. There are mixed results in terms of health and psychosocial outcomes, with specific subgroups doing better than others with technology. Our data demonstrated that patients have moderately elevated diabetes distress across differing types of technology used, from low-tech to high-tech options, possibly meaning that technology does not add or take away distress. In addition, users on multiple daily injections compared to all other technology groups have less positive attitudes about technology. Finally, we discuss implications for clinical practice and future research.
View details for DOI 10.1177/1932296816650900
View details for PubMedID 27234809
International and Interdisciplinary Identification of Health Care Transition Outcomes
2016; 170 (3): 205-211
There is a lack of agreement on what constitutes successful outcomes for the process of health care transition (HCT) among adolescent and young adults with special health care needs.To present HCT outcomes identified by a Delphi process with an interdisciplinary group of participants.A Delphi method involving 3 stages was deployed to refine a list of HCT outcomes. This 18-month study (from January 5, 2013, of stage 1 to July 3, 2014, of stage 3) included an initial literature search, expert interviews, and then 2 waves of a web-based survey. On this survey, 93 participants from outpatient, community-based, and primary care clinics rated the importance of the top HCT outcomes identified by the Delphi process. Analyses were performed from July 5, 2014, to December 5, 2014.Health care transition outcomes of adolescents and young adults with special health care needs.Importance ratings of identified HCT outcomes rated on a Likert scale from 1 (not important) to 9 (very important).The 2 waves of surveys included 117 and 93 participants as the list of outcomes was refined. Transition outcomes were refined by the 3 waves of the Delphi process, with quality of life being the highest-rated outcome with broad agreement. The 10 final outcomes identified included individual outcomes (quality of life, understanding the characteristics of conditions and complications, knowledge of medication, self-management, adherence to medication, and understanding health insurance), health services outcomes (attending medical appointments, having a medical home, and avoidance of unnecessary hospitalization), and a social outcome (having a social network). Participants indicated that different outcomes were likely needed for individuals with cognitive disabilities.Quality of life is an important construct relevant to HCT. Future research should identify valid measures associated with each outcome and further explore the role that quality of life plays in the HCT process. Achieving consensus is a critical step toward the development of reliable and objective comparisons of HCT outcomes across clinical conditions and care delivery locations.
View details for DOI 10.1001/jamapediatrics.2015.3168
View details for Web of Science ID 000372304700010
Diabetes in ethnically diverse youth: disparate burden and intervention approaches.
Current diabetes reviews
2015; 11 (4): 251-260
There is a rising prevalence of diabetes in youth and children, and the burden of this epidemic has shifted from primarily one affecting white youth to now affecting multiple ethnicities. As the incidence and prevalence of diabetes rise in ethnically diverse youth, indices of health and care in these populations are important to examine to understand the state of disparities and address them. Research reviewed indicates that there is evidence of disparities in glycemic control, as well as shortand long-term complications. Multisystemic factors contributing to these disparities include: 1) individual risk factors, 2) contextual risk factors, and 3) systemic risk factors. Interventions developed specifically to address these disparities, those that are tailored for these groups, and those that simply include ethnically diverse youth in their analyses are discussed below. Implications for future research and clinical practice are discussed.
View details for PubMedID 25901501
Predictors of Self-Management in Pediatric Type 1 Diabetes: Individual, Family, Systemic, and Technologic Influences
CURRENT DIABETES REPORTS
2014; 14 (11)
Type 1 diabetes (T1D) is a complex chronic disease that has many facets for successful management. The burden of this management falls largely on the individual and their family members. Self-management has a major influence on T1D health outcomes, and with successful management, children and adolescents with T1D can lead long and healthy lives. We discuss how various individual, family, and systemic/technologic factors influence T1D self-management, providing research that supports interventions targeting each of these factors. With this information, health care practitioners and researchers can better understand the role of T1D self-management and bolster this important aspect of T1D care.
View details for DOI 10.1007/s11892-014-0544-7
View details for Web of Science ID 000344325200004
View details for PubMedID 25200590
Age and Glycemic Control Among Low-Income Latinos
JOURNAL OF IMMIGRANT AND MINORITY HEALTH
2013; 15 (5): 898-902
Younger adult patients with diabetes often have poorer glycemic control (HbA1c) than older patients. It is not known if this relationship holds true in the Latino population. Objective was to explore the relationship between age and HbA1c in a Mexican American population and what plausible factors might mediate this relationship. We analyzed data from 387 patients with diabetes self-identified as Mexican American recruited as a part of a cross-sectional study of safety net patients in two cities. Patients completed questionnaires and their last HbA1c was extracted from the medical record. We conducted multivariate regression analyses and Baron and Kenny tests of mediation. Participants were young with mean age of 53 ± 12 years. Younger age was associated with a higher HbA1c and having a higher fat diet. High fat diet partially mediated the relationship between age and HbA1c (p < 0.001 to p < 0.01). Age's indirect effect on HbA1c through diet was significant (Sobel = -2.44, p = 0.01). Younger Mexican American patients had higher HbA1c compared to older patients. Having a diet high in fat partially explained this relationship. Future epidemiological studies are needed to understand the multifaceted relationship between age and glycemic control.
View details for DOI 10.1007/s10903-012-9689-0
View details for Web of Science ID 000323757500006
View details for PubMedID 22843322
REDEEM: A Pragmatic Trial to Reduce Diabetes Distress
2013; 36 (9): 2551-2558
To compare three interventions to reduce diabetes distress (DD) and improve self-management among non-clinically depressed adults with type 2 diabetes mellitus (T2DM).In REDEEM, 392 adults with T2DM and DD were randomized to computer-assisted self-management (CASM), CASM plus DD-specific problem solving (CAPS), or a computer-administered minimal supportive intervention. Primary outcomes were Diabetes Distress Scale (DDS) total, the Emotional Burden (EB) and Regimen Distress (RD) DDS subscales, and diet, exercise, and medication adherence.Significant and clinically meaningful reductions in DD (DDS, EB, and RD) and self-management behaviors occurred in all three conditions (P < 0.001), with no significant between-group differences. There was, however, a significant group × baseline distress interaction (P < 0.02), in which patients with high baseline RD in the CAPS condition displayed significantly larger RD reductions than those in the other two conditions. RD generated the most distress and displayed the greatest distress reduction as a result of intervention. The pace of DD reduction varied by patient age: older patients demonstrated significant reductions in DD early in the intervention, whereas younger adults displayed similar reductions later. Reductions in DD were accompanied by significant improvements in healthy eating, physical activity, and medication adherence, although not by change in HbA1c.DD is malleable and highly responsive to intervention. Interventions that enhance self-management also reduce DD significantly, but DD-specific interventions may be necessary for patients with high initial levels of DD. Future research should identify the minimal, most cost-effective interventions to reduce DD and improve self-management.
View details for DOI 10.2337/dc12-2493
View details for Web of Science ID 000323420200038
View details for PubMedID 23735726
Health and Psychosocial Outcomes in US Adult Patients with Diabetes from Diverse Ethnicities
CURRENT DIABETES REPORTS
2012; 12 (6): 729-738
Within the United States, diabetes is a serious public health concern and patients with diabetes are more likely to experience clinical depression, psychological distress, and depressive symptoms than those without. Negative psychosocial factors are associated with poorer diabetes management and glycemic control. Overall, both the rates of diabetes and related psychological distress are greater for persons of diverse ethnicities than for non-Latino whites, and have reached epidemic proportions in certain groups. The following article will provide an overview across ethnicities of the rates of diabetes, health outcomes, psychosocial outcomes, and unique cultural and linguistic challenges that contribute to disparities within US diabetes patients of diverse ethnicities. Using this information, our hope is that health care practitioners and researchers alike can better respond to the psychosocial needs of ethnically diverse patients.
View details for DOI 10.1007/s11892-012-0319-y
View details for Web of Science ID 000310706500012
View details for PubMedID 22961116
2012; 29 (5): 61-64
View details for PubMedID 23057179
Young adult African American patients with type 2 diabetes: A high risk patient sub-group with few supports for good diabetes management
JOURNAL OF HEALTH PSYCHOLOGY
2012; 17 (4): 535-544
This study examined age differences in support, BMI, and HbA1c among African American patients with type 2 diabetes. Participants were 158 African American adults with type 2 diabetes. Average HbA1c was 1% higher among patients aged 20-49 than patients 60-77, and double the number of younger patients had a BMI ≥35 than older patients. Younger patients reported less trust in their physician and greater disagreement with recommendations. They reported relying less on partners, greater unresolved conflict with partners around diabetes, and less church involvement. The association between age and HbA1c was partially mediated by patients' trust of their physician.
View details for DOI 10.1177/1359105311422120
View details for Web of Science ID 000303396100008
View details for PubMedID 21963680
AASAP: A program to increase recruitment and retention in clinical trials
PATIENT EDUCATION AND COUNSELING
2012; 86 (3): 372-377
To evaluate a theory based, subject-centered, staff/subject communication program, AASAP (anticipate, acknowledge, standardize, accept, plan), to increase recruitment and retention in RCTs.AASAP was evaluated with logistical regression by comparing rates of recruitment (at telephone screening, baseline assessment, initial intervention) and intervention retention (over 16 weeks) before (-AASAP) and after (+AASAP) it was introduced to a 3-arm RCT to reduce disease distress among highly distressed subjects with type 2 diabetes.Included were 250 subjects in -AASAP and 338 in +AASAP. Significant improvement in recruitment occurred at each of the 3 recruitment stages: agreed at screening (OR=2.52; p<0.001), attended baseline assessment (OR=1.91; p<0.001), attended initial intervention (OR=1.46; p<0.03). Higher education and shorter diabetes duration predicted better recruitment in -AASAP (OR=2.23; p<0.001), but not in +AASAP. AASAP also improved intervention retention over 16 weeks (OR=3.46; p<0.05).AASAP is a structured program of subject/staff communication that helps improve external validity by enhancing both subject recruitment and retention.AASAP can be taught to non-professional staff and can be adapted to a variety of health settings. It can also be used by clinicians to engage patients in programs of ongoing care.
View details for DOI 10.1016/j.pec.2011.07.002
View details for Web of Science ID 000302672700016
View details for PubMedID 21831557
Patients With Type 2 Diabetes at Risk for Major Depressive Disorder Over Time
ANNALS OF FAMILY MEDICINE
2011; 9 (2): 115-120
We wanted to identify risk factors associated with the development of major depressive disorder (MDD) among patients with type 2 diabetes over time.In a noninterventional study, 338 adult patients with type 2 diabetes and no MDD diagnosis at baseline were assessed 3 times during 18 months (9-month intervals) to ascertain predictors of MDD. We tested a model incorporating personal, behavioral, biologic, and psychosocial variables to identify predictors of MDD. Exploratory analyses tested whether current negative affect mediated the relationship between predictors and subsequent MDD. We also conducted a stratified analysis of moderate vs high negative affect to explore whether level of baseline negative affect mediated the relationship between specific predictors and MDD.Prior MDD and negative affect predicted future development of MDD. In subpopulations stratified by moderate negative affect, negative life events, an elevated body mass index (BMI), prior MDD, and poor control of glycated hemoglobin (hemoglobin A(1c)) each predicted MDD. In subpopulations stratified by elevated negative affect, negative life events and poor control of hemoglobin A(1c) predicted MDD. Current negative affect partially mediated the relationship between prior MDD and subsequent MDD, as well as the relationship between negative life events and subsequent MDD.Although negative affect at baseline was the primary predictor of subsequent MDD, when stratified by negative affect, negative life events, BMI, and poor control of hemoglobin A(1c) also predicted MDD. Thus, life stresses and patients' disease-related concerns are important when understanding what predicts subsequent MDD. Addressing depressive symptoms and broader life context issues expands the scope of a potential intervention to reduce the risk of developing MDD in persons with type 2 diabetes.
View details for DOI 10.1370/afm.1212
View details for Web of Science ID 000289024100005
View details for PubMedID 21403137
Substance use treatment outcomes in a sample of male serious juvenile offenders
JOURNAL OF SUBSTANCE ABUSE TREATMENT
2009; 36 (2): 183-194
This study examined drug-treatment-related reductions in alcohol and marijuana use, cigarette smoking, and nondrug offending among male adolescents who had been adjudicated of a serious (almost exclusively felony) offense. Results indicated that the "real-world" drug treatments that these adolescents experienced had significant effects on substance use, which could not be explained solely by incarceration in controlled environments. However, effects on cigarette smoking and criminal offending were found only for treatments that included family involvement. Results suggest that involving families in adolescents' treatment may be useful for promoting desistence from criminal offending in this population.
View details for DOI 10.1016/j.jsat.2008.06.001
View details for Web of Science ID 000263305700007
View details for PubMedID 18657942
Cultural traditions as "protective factors" among Latino children of illicit drug users
SUBSTANCE USE & MISUSE
2007; 42 (4): 621-642
Family bonding was examined among Hispanic adolescents whose fathers are illicit drug users to ascertain whether such adolescents maintain close affective family ties or alienate themselves from their families given their father's use of illicit drugs and referral to a drug screening and treatment program. It was hypothesized that high levels of paternal drug use would be associated with the youth's alienation from the family. In addition, it was postulated that the adolescent's endorsement of traditional cultural values and social responsibility would protect her or him against this effect in relation to family bonding. These hypotheses are based on prior research that suggests that youth bonding to prosocial institutions, such as family, school, church, and community organizations, can be "protective" against drug use. More specifically, our analyses examined the role of level of acculturation in middle school, family traditionalism, American orientation, Latino orientation, and social responsibility in predicting adolescents' family bonding. Results indicated that the father's level of marijuana and/or methamphetamine use was unrelated to youth family bonding. Additionally, Latino and American cultural orientations and level of acculturation in middle school were not associated with family bonding. By contrast, social responsibility (the youth's citizenship and responsibility to the community) and family traditionalism (endorsing conservative cultural values regarding the maintenance of family traditions and respect for elders and family) were significantly associated with family bonding. In other words, among children of Latino illicit drug users, the youth's conservative family values and a responsible attitude toward community traditions were dual factors related to family bonding, perhaps operating also as sources of "protection" against youth problem behaviors.
View details for DOI 10.1080/10826080701202247
View details for Web of Science ID 000246961400003
View details for PubMedID 17558954