ISPAD Clinical Practice Consensus Guidelines 2014. Assessment and monitoring of glycemic control in children and adolescents with diabetes

International benchmarking in type 1 diabetes: Large difference in childhood HbA1c between eight high-income countries but similar rise during adolescence-A quality registry study

OBJECTIVES

To identify differences and similarities in HbA1c levels and patterns regarding age and gender in eight high-income countries.

SUBJECTS

66 071 children and adolescents below18 years of age with type 1 diabetes for at least 3 months and at least one HbA1c measurement during the study period.

METHODS

Pediatric Diabetes Quality Registry data from Austria, Denmark, England, Germany, Norway, Sweden, the United States, and Wales were collected between 2013 and 2014. HbA1c, gender, age, and duration were used in the analysis.

RESULTS

Distribution of gender and age groups was similar in the eight participating countries. The mean HbA1c varied from 60 to 73 mmol/mol (7.6%-8.8%) between the countries. The increase in HbA1c between the youngest (0-9 years) to the oldest (15-17 years) age group was close to 8 mmol/mol (0.7%) in all countries (P < .001). Females had a 1 mmol/mol (0.1%) higher mean HbA1c than boys (P < .001) in seven out of eight countries.

CONCLUSIONS

In spite of large differences in the mean HbA1c between countries, a remarkable similarity in the increase of HbA1c from childhood to adolescence was found.

Mean blood glucose-independent HbA1c racial disparity and iron status in youth with Type 1 DM

INTRODUCTION

Black patients have higher HbA1c than Whites even after adjustment for mean blood glucose (MBG). Decreased iron status has been associated with increased HbA1c independently of glucose. We hypothesized that decreased iron status might account for higher HbA1c in Black patients.

METHODS

Pediatric patients with T1D in the Diabetes Center at Children's Hospital of New Orleans who self-identified as either Black or White were recruited for the study. At the time of their clinic visit labs were obtained for ferritin (Fer), soluble transferrin receptor (sTfR), HbA1c, and CBC. MBG was derived from patient's home glucose meter records over the last 30 days. Total body iron (TBI) and sTfr/log₁₀ Fer (R/lFer) were calculated.

RESULTS

A total of 80 (35 Blacks/45 Whites; 41 female/39 male) patients were recruited. Unadjusted levels of HbA1c, MBG, sTfR, Fer, RDW-CV, and RDW-SD were all higher in Blacks than Whites. TBI and R/lFer were not different between groups. Fer was correlated with Hb, MBG but not HbA1c. sTfR was correlated with HbA1c, MCV, MCH, and RDW-SD. In multiple variable analysis with HbA1c as the dependent variable, race and MBG were statistically significant in the model. However, measures of iron status: Fer, sTfR, R/lFer and TBI were not statistically influential.

CONCLUSION

After adjustment for race, MBG and RDW-CV, iron indices were not statistically significant independent predictors of HbA1c levels. These observations indicate that factors besides iron status and CBC indices contribute to MBG-independent racial disparity in HbA1c.

Individual and Family Management in Portuguese Adolescents with Type 1 Diabetes: a Path Analysis

BACKGROUND

This study evaluates the adequacy of the Revised Self and Family Management Framework (Grey et al., Nurs Outlook 63:162-170, 2015) in Portuguese adolescents with type 1 diabetes and analyzes the effect of parental coping, family support, and adherence in the association between illness representations, school support, metabolic control, quality of life, and family functioning.

METHOD

One hundred adolescents (aged 12-19) and their parents participated in a cross-sectional study. Adolescents were assessed on school support, adherence to self-care, family support, and quality of life. Parents were assessed on parental coping and family functioning. Both adolescents and parents were assessed on illness representations. Adolescent's metabolic control was evaluated through glycosylate hemoglobin.

RESULTS

Adolescents' and parents' illness representations were associated with metabolic control, quality of life and family functioning. Parental coping, family support and adherence had an indirect effect between illness representations and diabetes outcomes.

CONCLUSION

Findings showed the adequacy of Grey and colleagues' model (Nurs Outlook 63:162-170, 2015) in adolescents with type 1 diabetes and how family support, parental coping, and adherence contribute to diabetes management. Interventions to improve adolescents' and family's management of Type 1 diabetes should be designed to change adolescents' and family's representations and enhance their ability and skills in diabetes management.

Decreased markers of bone turnover in children and adolescents with type 1 diabetes

BACKGROUND AND AIM

Adults with type 1 diabetes (T1D) have increased risk of bone fractures and decreased bone mineral density (BMD). Alterations in bone turnover have been suggested as the link between T1D and the impaired bone health. Furthermore, bone turnover has been suggested to have beneficial effects on glucose metabolism. This study aimed at describing bone turnover markers (BTM), and the relationship with glycemic control, in children and adolescents with T1D.

METHODS

A total of 173 (47% girls) children and adolescents aged 7.7 to 17.5 years with T1D for more than 1 year were included. Participants were evaluated by BMD together with measurements of selected BTM; two formation markers: osteocalcin (OCN) and procollagen type-1 amino-terminal propeptide (P1NP) and one resorption marker, C-terminal cross-linked telopeptide of type-1 collagen (CTX). BTM were converted into Z-scores utilizing new national references.

RESULTS

Mean OCN Z-score (-0.68 ± 1.31), P1NP Z-score (-0.33 ± 1.03) and CTX Z-score (-0.43 ± 1.10) were all significantly lower than the reference population (P < .001). No associations were seen between BTM and T1D duration. BMD Z-score was comparable to the reference population and associated with none of individual BTMs. CTX Z-score was negatively associated with HbA1c (P = .007) independent of both exogenous and residual endogenous insulin.

CONCLUSIONS

Markers of bone formation and resorption were decreased in children and adolescents with T1D. CTX Z-score associated negatively with HbA1c adjusted for insulin treatment and endogenous insulin production indicating a potential association between CTX and insulin sensitivity. The long-term consequences of decreased BTM on BMD need further attention.

The Transatlantic HbA1c gap: differences in glycaemic control across the lifespan between people included in the US T1D Exchange Registry and those included in the German/Austrian DPV registry

AIM

To compare HbA_1c levels across the lifespan in people with type 1 diabetes in the USA with those in Germany/Austria, and to examine potential differences in HbA_1c levels between sexes, insulin delivery methods and minority status.

METHODS

Data were extracted from the US T1D Exchange Registry (n=18 381 participants from 73 sites) and from the German/Austrian Prospective Diabetes Follow-up Registry, the DPV (n=32 643 participants from 362 sites). Mean HbA_1c was calculated for each year of age for individuals aged ≤25 years, and at 2-year age intervals for individuals aged >25 years. Curves for mean HbA_1c by age were estimated using locally weighted scatterplot smoothing. HbA_1c differences between registries, sexes, insulin delivery methods, and minority status were assessed by age group using multiple linear regression.

RESULTS

In both registries, mean HbA_1c increased by ~11 mmol/mol (1.0%) between the ages of 9 and 18 years, although at quite different absolute levels: from 66 mmol/mol (8.2%) to 77 mmol/mol (9.2%) in the T1D Exchange Registry, and from 56 mmol/mol (7.3%) to 66 mmol/mol (8.2%) in the DPV. Sex differences were observed in the DPV only. In the T1D Exchange Registry, injection users had higher mean HbA_1c than pump users across the lifespan, whereas in the DPV higher HbA_1c levels in injection users were observed in the age groups 6 to <12 years, 12 to <18 years, and 30 to <50 years (P < 0.001). Minority status was significantly associated with higher HbA_1c in most age groups in both registries.

CONCLUSIONS

Significant differences in HbA_1c were noted between the USA and Germany/Austria, with disparities more pronounced in early childhood through to young adulthood. Further studies should identify causes for these disparities.

Randomised controlled trial of a person-centred transition programme for adolescents with type 1 diabetes (STEPSTONES-DIAB): a study protocol

INTRODUCTION

Adolescence is a critical period for youths with chronic conditions, when they are supposed to take over the responsibility for their health. Type 1 diabetes (T1D) is one of the most common chronic conditions in childhood and inadequate self-management increases the risk of short-term and long-term complications. There is a lack of evidence regarding the effectiveness of transition programmes. As a part of the Swedish Transition Effects Project Supporting Teenagers with chrONic mEdical conditionS research programme, the objective of this study is to evaluate the effectiveness and experiences of different transitional care models, including a person-centred transition programme aiming to empower adolescents with T1D to become active partners in their health and care.

METHODS AND ANALYSIS

In this randomised controlled trial, patients are recruited from two paediatric diabetes clinics at the age of 16 years. Patients are randomly assigned to either the intervention group (n=70) where they will receive usual care plus the structured transition programme, or to the control group (n=70) where they will only receive usual care. Data will be collected at 16, 17 and 18.5 years of age. In a later stage, the intervention group will be compared with adolescents in a dedicated youth clinic in a third setting. The primary outcome is patient empowerment. Secondary outcomes include generic, diabetes-specific and transfer-specific variables.

ETHICS AND DISSEMINATION

The study has been approved by the Ethical Review Board in Stockholm (Dnr 2018/1725-31). Findings will be reported following the Consolidated Standards of Reporting Trials statement and disseminated in peer-reviewed journals and at international conferences.

TRIAL REGISTRATION NUMBER

NCT03994536.

Glycaemic control across the lifespan in a cohort of New Zealand patients with type 1 diabetes mellitus

BACKGROUND

It is well known that tight glycaemic control reduces all-cause mortality and the development of microvascular complications in patients with type 1 diabetes mellitus (T1D), but that effective glycaemic control is difficult to achieve in different age groups. Currently, the state of glycaemic control across the lifespan in patients with T1D in New Zealand is not known.

AIM

To determine the differences in glycaemic control with age, gender, rurality and ethnicity in patients with T1D in the Waikato region of New Zealand.

METHODS

Retrospective review of clinical records of all patients with T1D on the Waikato Regional Diabetes Database in December 2017 (n = 1303). Glycaemic control was determined by the most recent HbA1c in the past 2 years.

RESULTS

Median (25%, 75%) HbA1c was 67 (59, 81) mmol/mol (8.3%) and highest in those aged 15-29 years. Values exceeded clinical recommendations in 85.3% of all patients. Median HbA1c was lower in patients on insulin pump therapy than on multiple daily injections (63 (7.9%) versus 69 mmol/mol (8.5%); P < 0.001), though insulin pumps were significantly less likely to be used by Māori (P = 0.003) and men (P < 0.0001). Worsening glycaemic control was associated with increasing social deprivation (P < 0.001) but was not influenced by rural/urban living.

CONCLUSIONS

Poor glycaemic control in Waikato patients with T1D is likely due to inequities in health care, including reduced access to insulin pump therapy, particularly in Māori and socially deprived populations.

Glycemic control in adolescents with type 1 diabetes: Are computerized simulations effective learning tools?

OBJECTIVE

Type 1 diabetes mellitus (T1DM) in adolescent patients is often characterized by poor glycemic control. This study aimed at exploring the contribution of learning with computerized simulations to support: (a) mechanistic understanding of the biochemical processes related to diabetes; (b) diabetes self-management knowledge; and (c) glycemic control. We hypothesized that learning with such simulations might support adolescents in gaining a better understanding of the biochemical processes related to glucose regulation, and consequently improve their glycemic control.

METHODS

A prospective case-control study was conducted in 12- to 18-year-old adolescents with T1DM (n = 85) who were routinely treated at an outpatient diabetes clinic. While the control group (n = 45) received the routine face-to-face follow-up, the intervention group (n = 40) learned in addition with computerized simulations that were embedded in pedagogically supportive activities. Participants in both groups completed a set of questionnaires regarding sociodemographic characteristics, diabetes mechanistic reasoning and diabetes self-management. Clinical data and serum glycated hemoglobin (HbA1c) levels were gathered from medical records. All the data was collected at recruitment and 3 months later.

RESULTS

Analysis revealed improvement HbA1c levels in the intervention group (8.7% ± 1.7%) vs the controls (9.6% ± 1.6%) after 3 months (P < .05). Regression analysis showed that levels of diabetes mechanistic understanding and diabetes self-management knowledge, in addition to sociodemographic parameters, accounted for 31% of the HbA1c variance (P < .001).

CONCLUSION

These results suggest that learning with computerized simulations about biochemical processes can improve adolescents' adherence to medical recommendations and result in improved glycemic control. Implementing scientific learning into the hospital educational setting is discussed.

Initial experiences of adolescents and young adults with type 1 diabetes and high-risk glycemic control after starting flash glucose monitoring - a qualitative study

Purpose

This study explored early experiences with a flash glucose monitoring system among adolescents and young adults with type 1 diabetes and high-risk glycemic control.

Methods

Adolescents and young adults with high-risk glycemic control (HbA1c ≥ 75 mmol/mol (9.0%) in the previous 6 months) who had recently commenced on flash glucose monitoring as part of a trial took part in a semi-structured interview exploring their experiences with the technology. All interviews were recorded, transcribed and analyzed using an inductive approach.

Results

Fifteen interviews were conducted. Overall, participants enjoyed flash glucose monitoring and planned to continue using their system. Key findings included flash glucose monitoring reduced diabetes management burden and increased glucose monitoring. Other impacts of flash glucose monitoring use included perceived improved mood and energy, increased capacity for physical activity and less parental conflict. While participants reported healthier glycemic control, participants' mean interstitial glucose level remained above the target range of 3.9-10.0 mmol/L (70-180 mg/dL) over the first month of flash glucose monitoring. Common challenges included premature sensor loss and decreased scanning over the first month of use.

Conclusions

Flash glucose monitoring may be an acceptable self-management tool to increase monitoring frequency in adolescents and young adults with type 1 diabetes and high-risk glycemic control, with the potential to improve long-term glycemic control. Initial support efforts should focus on practical strategies to prolong sensor wear and motivate frequent scanning as well as education on interpreting glucose data and making informed treatment decisions to maximize the benefits of this technology.

Impact of Socioeconomic Characteristics on Metabolic Control in Children with Type 1 Diabetes in a Developing Country

OBJECTIVE

Adequate glycemic control in children with type 1 diabetes reduces the risk of future complications. Identifying factors affecting haemoglobin A1c (HbA1c) is crucial to management of metabolic control. We aimed to identify possible socioeconomic predictors of poor metabolic control this patient group in Jordan, a developing country with limited resources.

METHODS

Medical charts of children with type 1 diabetes attending the pediatric endocrine clinics in two major diabetes centers were reviewed. HbA1c ≥7.5% (58 mmol/mol) was considered to reflect poor metabolic control. Logistic regression analysis was performed to identify predictors of poor glycemic control. The association between socioeconomic characteristics and metabolic control was evaluated using multiple correspondence analysis (MCA).

RESULTS

Two hundred and fifty-nine children were enrolled in the study. One fifth of the patients (20.5%) achieved HbA1c <7.5%. Patients with dietary non-compliance [odds ratio (OR): 3.533, confidence interval (CI): 1.803 - 6.926; p<0.001], and those who were overweight (OR: 3.869, CI: 1.218 - 12.294; p=0.022) were more likely to have poor metabolic control. Children whose mothers had a bachelor’s degree or higher were less likely to have poor metabolic control compared to children whose mothers had only elementary education (OR: 0.241, CI: 0.079 - 0.734; p=0.012). MCA revealed an association between low socioeconomic status and poor metabolic control. Children with deceased mothers had significantly higher HbA1c of 10.6±1.86% compared to an average of 8.7±1.45% for the rest of participants (p=0.005).

CONCLUSION

Low socioeconomic status, lower levels of maternal education and maternal death were associated with poor metabolic control. Identifying children with these risk factors might play an important role in optimizing metabolic control and provide better diabetes care.

New insulin delivery devices and glycemic outcomes in young patients with type 1 diabetes: a protocol for a systematic review and meta-analysis

BACKGROUND

Optimal type 1 diabetes mellitus (T1D) care requires lifelong appropriate insulin treatment, which can be provided either by multiple daily injections (MDI) of insulin or by continuous subcutaneous insulin infusion (CSII). An increasing number of trials and previous systematic reviews and meta-analyses (SRMA) have compared both CSII and MDI but have provided limited information on equity and fairness regarding access to, and the effect of, those insulin devices. This study protocol proposes a clear and transparent methodology for conducting a SRMA of the literature (1) to assess the effect of CSII versus MDI on glycemic and patient-reported outcomes (PROs) among young patients with T1D and (2) to identify health inequalities in the use of CSII.

METHODS

This protocol was developed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P), the PRISMA-E (PRISMA-Equity 2012 Guidelines), and the Cochrane Collaboration Handbook. We will include randomized clinical trials and non-randomized studies published between January 2000 and June 2019 to assess the effectiveness of CSII versus MDI on glycemic and PROs in young patients with T1D. To assess health inequality among those who received CSII, we will use the PROGRESS framework. To gather relevant studies, a search will be conducted in MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Database of Systematic Reviews, and the Health Technology Assessment (HTA) database. We will select studies that compared glycemic outcomes (the glycosylated hemoglobin values, severe hypoglycemia episodes, diabetic ketoacidosis events, and/or time spent in range or in hyper-hypoglycemia), and health-related quality of life, as a PRO, between therapies. Screening and selection of studies will be conducted independently by two researchers. Subgroup analyses will be performed according to age group, length of follow-up, and the use of adjunctive technological therapies that might influence glycemic outcomes.

DISCUSSION

Studies of the average effects of CSII versus MDI may have not assessed their impact on health equity, as some intended populations have been excluded. Therefore, this study will address health equity issues when assessing effects of CSII. The results will be published in a peer-review journal. Ethics approval will not be needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018116474.

Documenting and visualising progress towards Universal Health Coverage of insulin and blood glucose test strips for people with diabetes

AIMS

Global governments have committed to achieve Universal Health Coverage (UHC), ensuring access to quality and affordable healthcare for all. This is fundamental for those with type 1 diabetes mellitus, who require daily access to both insulin and blood glucose test strips to survive. This group risks being left behind by global initiatives that fail to consider these particular needs.

METHODS

A questionnaire was distributed to key informants in 37 less-resourced countries. Seven high-income countries were also included for comparison. We drew on a WHO framework developed to assess progress towards UHC to create scales on three dimensions: population covered, services provided and direct costs. A fourth dimension, availability, was added. Results were grouped into six patterns and visually displayed with radar graphs.

RESULTS

65% of the less-resourced national health systems provided insulin, with medians of 67% for service provision (equating to Human Regular and NPH), 55% direct costs covered, and 75% availability. Test strips were only provided in 14% of the less-resourced systems, with medians 42% (less than two strips per day), 76%, and 88% respectively. Six patterns of provision were identified. Progress correlated with income level, yet some low-income countries are achieving provision for insulin and test strips for those enrolled in health insurance schemes.

CONCLUSION

No less-resourced country had even near-complete coverage for insulin, and coverage was worse for test strips. This study demonstrates the utility of this framework which could be developed as a means of tracking progress in meeting the needs of people with diabetes.

Impact of attention deficit hyperactivity disorder on metabolic control in adolescents with type1 diabetes

OBJECTIVE

Diabetes mellitus type 1 (T1D) incidence is increasing in pediatric population. Good metabolic control, measured by glycated hemoglobin (HbA_1c), significantly reduces the risk for chronic complications. Comorbid disorders, including attention-deficit hyperactivity disorder (ADHD), may influence glycemic control. To date little is known about the prevalence of ADHD among adolescents with T1D and its influence on diabetes self-management. Therefore, we aimed to identify adolescents with T1D and ADHD and assess the effect of ADHD on metabolic control.

METHOD

This cross-sectional case-control study included 101 patients (11-17 years old) with T1D. Development and Well-Being Assessment (DAWBA) questionnaire and subsequent psychiatric clinical examination were used to identify ADHD in a group with T1D. Indicators of metabolic control were collected from available medical documentation for preceding 12 months and compared between the group of patients with T1D and ADHD and the group of T1D patients without ADHD.

RESULTS

ADHD was diagnosed in 11.9% adolescents with T1D (12 of 101). We found a statistically significant difference (p = .022) in HbA_1c between the two groups - higher in the group with T1D and ADHD (8.4% or 68.3 mmol/mol) than in the group with T1D without ADHD (7.8% or 61.7 mmol/mol).

CONCLUSIONS

Almost 12% of adolescents with type 1 diabetes were diagnosed with ADHD and they had poorer glycemic control. Adolescents with T1D and ADHD must be diagnosed early and offered appropriate treatment focused on preventing negative ADHD impact on metabolic control.

Audit of glycemic control in patients with type 1 diabetes referred to a pediatric clinic in a specialized center in Kuwait

INTRODUCTION

Intensive glycemic control reduces the risk of microvascular and macrovascular complications. Furthermore, optimal glycemic control is essential for normal growth and development. Thus, there is a need to monitor and evaluate glycemic control in patients with type 1 diabetes (T1D). Our aim was to audit glycemic control in patients with T1D in a specialized center as per the Society of Pediatric and Adolescent Diabetes (ISPAD) Hemoglobin A1C (HbA1C) target recommendations published in 2014.

METHODS

This is a retrospective cross-sectional study reporting on glycemic control (HbA1C) of patients younger than 21 years of age and with T1D treated at Dasman Diabetes Institute (DDI) between January 2013 and December 2015.

RESULTS

A total of 470 patients with T1D (250 males and 220 females) were included. Only 53 (11.3%) patients met the ISPAD target for optimal glycemic control with HbA1C < 7.5% (58 mmol/mol). Older age was positively associated with poor glycemic control (p = 0.001) while Continuous Subcutaneous Insulin Infusion (CSII) therapy was negatively associated with poor glycemic control, adjusted Odds Ratio (OR) 0.33 (95% confidence interval (CI): 0.16-0.66) for CSII and adjusted OR 0.42 (95% CI: 0.27-0.64) for shifting to CSII (p < 0.001).

CONCLUSION

Achieving optimal glycemic control is a significant challenge for young patients with T1D. Glycemic control goals should be individualized to achieve such goals safely, realistically and with a better quality of life for patients with T1D.

A case of treatment-induced neuropathy in an adolescent with type 1 diabetes

Treatment-induced neuropathy (TIN) in diabetes is an acute and painful yet completely reversible small fiber neuropathy precipitated by a rapid improvement in glycemic control. TIN is rare in children. A 16-year-old girl developed symmetrical painful neuropathy of the foot, autonomic neuropathy, and retinopathy 5 weeks after the diagnosis of type 1 diabetes. All causative workups were negative except for a drop-in hemoglobin A1c (HbA1c) from 17.4% to 7%, which fit with a diagnosis of TIN. Following symptomatic management, her neuropathy and retinopathy completely resolved in 2 months. Currently, she is 18 years old and doing well (HbA1c, 7.4%) without any recurrence of TIN. TIN should be suspected in any child presenting with recent-onset type 1 diabetes and acute onset neuropathy. Our case represents an unreported scenario of the rapid progression in TIN. Awareness among clinicians about this rare but completely reversible condition is necessary to ensure proper management and adherence to glycemic control.

Long-term safety of α-1 antitrypsin therapy in children and adolescents with Type 1 diabetes

Promising findings of α-1 antitrypsin (AAT) intervention in mice models of Type 1 diabetes (T1D) led researchers to investigate AAT as a therapeutic modality for β-cell preservation in recent-onset T1D patients. Our prospective, open-label Phase I/II extension study demonstrated that the administration of multiple repeated AAT infusions (up to 36) to AAT-sufficient pediatric T1D patients is safe and well-tolerated. Long-term surveillance of participants (up to 5 years) from diabetes onset revealed normal growth and pubertal progression through adolescence to attainment of full puberty and near adult height. No serious adverse events, clinical or laboratory abnormalities were reported. Given its safety profile, AAT may be an individualized-tailored innovative immunotherapy in AAT-sufficient pediatric patients with diverse immune-related medical conditions. ClinicalTrials.gov Identifier: NCT01661192.

The Relationships Among School Nurse to Student Ratios, Self-Efficacy, and Glycemic Control in Adolescents With Type 1 Diabetes

Adolescents with Type 1 diabetes (T1D) experience unique self-management challenges, which can lead to poor glycemic control and sequelae. School nurses may impact student self-efficacy behaviors for T1D management in adolescents. The purpose of this study was to determine the relationships among school nurse staffing patterns, measured by school nurse to student ratios, self-efficacy, and glycemic control in adolescents with T1D. The sample consisted of 89 parent–adolescent dyads. Adolescents aged 10–16 years old with T1D completed the Self-Efficacy for Diabetes Self-Management (SEDM) Scale. Parents completed a demographic questionnaire. Higher school nurse to student ratios correlated with better glycemic control and older age. Higher SEDM scores correlated with older age, and females scored significantly higher. Findings contribute new knowledge to the paucity of literature on school nursing and adolescents with T1D, with implications for nursing practice, education, research, and policy.

Adherence to diabetes care: Knowledge of biochemical processes has a high impact on glycaemic control among adolescents with type 1 diabetes

AIM

To evaluate the impact of patients' understanding of biochemical processes involved in glucose regulation (causal-biochemical knowledge) and of diabetes self-management knowledge on adherence to treatment recommendations among adolescents with type 1 diabetes mellitus.

DESIGN

A cross-sectional study.

METHODS

Adolescents with type 1 diabetes mellitus, aged 12-18 years and able to read and write in Hebrew or in Arabic were eligible. Participants were recruited between August 2016 - January 2018 during routine visits to the Paediatric Diabetes Clinic; informed consent was obtained as customary. Patients completed sociodemographic, clinical and type 1 diabetes mellitus self-management and biochemical knowledge questionnaires. Adherence to treatment was assessed by patients' serum HbA1c levels, collected from medical records.

RESULTS

Ninety-seven patients participated in the study. Mean HbA1c levels were 9.2% (1.9%) and only 24 (24.7%) patients met the recommended HbA1c ≤ 7.5%. Lower HbA1c levels were strongly associated with higher family income, older age at diagnosis and with better type 1 diabetes mellitus self-management and causal-biochemical knowledge. A regression model showed that causal-biochemical knowledge contributed to the variance in HbA1c levels. Furthermore, causal-biochemical knowledge, but not self-management knowledge, was found to mediate the negative relationship between low family income and high HbA1c levels.

CONCLUSIONS

Causal-biochemical knowledge is a valuable component for the adherence to diabetes care and glycaemic control.

IMPACT

Our study suggests that causal knowledge is a valuable component that should be included in nursing and healthcare educational programmes for adolescents with type 1 diabetes mellitus.

Early Initiation of Diabetes Devices Relates to Improved Glycemic Control in Children with Recent-Onset Type 1 Diabetes Mellitus

Objective: To test whether the addition of an insulin pump or continuous glucose monitor (CGM) related to reduced glycated hemoglobin A1c (HbA1c) in large cohort of children, 5-9 years old, and within 1 year of their type 1 diabetes (T1D) diagnosis. Research Design and Methods: The study uses data from families of children with recent-onset T1D and who were between 5 and 9 years old. Study analyses used children's HbA1c values at baseline and at the 6-month follow-up. Parents reported on family demographics and children's T1D device use in their daily management (e.g., insulin pump or CGM). Children's mean T1D duration was 4.70 ± 3.28 months at baseline, so the 6-month assessment point was ∼12 months postdiagnosis. Results: One hundred-eleven families participated. At baseline, child mean age was 7.51 ± 1.37 years, and mean child HbA1c was 7.65% ± 1.40%. In addition, 17% of children used an insulin pump, and 17.1% of children used CGM. Six months later, 35.1% of children had started an insulin pump and 25.2% had started CGM. Repeated measures analyses of variance results showed a smaller overall HbA1c between baseline and 6 months for children using an insulin pump versus children not on a pump. For CGM, results showed that children starting a CGM during this window had a significantly lower HbA1c level than children who had not started on CGM. Conclusions: The study results suggest that early initiation of either an insulin pump or CGM in children newly diagnosed with T1D may help to improve child HbA1c levels within the first 12 months of diabetes.

PARTIAL HOSPITALIZATION: AN INTERVENTION FOR YOUTH WITH POORLY CONTROLLED DIABETES MELLITUS

Objective: To examine the efficacy of an integrated medical/psychiatric partial hospitalization program (PHP) to improve glycemic control in youth with both diabetes mellitus and mental health disorders. Methods: This retrospective chart review is of patients admitted to a PHP between 2005-2015 with concerns about diabetes mellitus care. Clinical characteristics, laboratory data, diabetic ketoacidosis hospitalizations, and outpatient clinic visit frequency were collected from the year prior to the year after PHP admission. Results: A total of 43 individuals met inclusion criteria: 22 (51%) were female, 40 (93%) had type 1 diabetes, the mean age was 15.2 ± 2.3 years, and the mean diabetes mellitus duration was 4.6 ± 3.6 years. Of those individuals, 35 of these patients had hemoglobin A1c (HbA1c) data available at baseline, 6 months, and 1 year after PHP. The average HbA1c before PHP admission was 11.3 ± 2.3% (100.5 ± 25 mmol/mol), and decreased to 9.2 ± 1.3% (76.7 ± 14.8 mmol/mol) within 6 months of PHP admission (P<.001). The average HbA1c 1 year after PHP was 10.7 ± 1.7 % (93.3 ± 19.1 mmol/mol). Overall, 24 patients (68%) had lower HbA1c, and 75% of those with improvement maintained an HbA1c reduction of ≥1% (≥10 mmol/mol) at 1 year compared to before PHP. Conclusion: Most patients demonstrated improved glycemic control within 6 months of PHP admission, and many of those maintained a ≥1% (≥10 mmol/mol) reduction in HbA1c at 1 year following PHP admission. This program may represent a promising intervention that could serve as a model for intensive outpatient management of youth with poorly controlled diabetes mellitus. Abbreviations: ADA = American Diabetes Association; DKA = diabetic ketoacidosis; EMR = electronic medical record; HbA1c = hemoglobin A1c; ICD-9 = International Classification of Diseases, 9^th revision; PHP = partial hospitalization program.

[Improving the management of children with type 1 diabetes and their families: What role for the advanced practice nurse, coordinator of complex care pathways? A qualitative, exploratory study using semi-directed interviews]

BACKGROUND

Type 1 diabetes in children in Switzerland is becoming increasingly prevalent. The coordination of care seems to be a determining element and is essential for effective and efficient care.

OBJECTIVE

Identify the difficulties and the levers of coordination faced by healthcare workers and families during the discovery of type 1 diabetes in children aged from birth to fifteen.

METHOD

Qualitative analysis using semi-directed interviews.

RESULTS

Three families and five healthcare workers participated in the study. Confirmation of the diagnosis was received badly and was a shock for the families. Nurses specializing in pediatric diabetes are recognized for being experts in diabetes care and education. Non-specialist nurses consider diabetes care to be stressful and complex. Collaboration between units is described as compartmentalized. ICT tools are not shared between units. Psychological support is considered to be unsatisfactory by the families.

DISCUSSION

Interdisciplinary nurses need to work together and with a structured coordination of care.

Factors Affecting Cardiovascular Risk in Children, Adolescents, and Young Adults with Type 1 Diabetes

Cardiovascular risk and obesity are becoming major health issues among individuals with type 1 diabetes (T1D). The aim of this study was to evaluate cardiovascular risk factors and obesity in youth with T1D in Lithuania. Methods. 883 patients under 25 years of age with T1D for at least 6 months were investigated. Anthropometric parameters, blood pressure, and microvascular complications were evaluated, and the lipid profile and HbA1c were determined for all patients. Results. Study subjects' mean HbA1c was 8.5 ± 2%; 19.5% were overweight and 3.6% obese. Hypertension and dyslipidemia were diagnosed in 29.8% and 62.6% of participants, respectively. HbA1c concentration was directly related to levels of total cholesterol (r = 0.274, p < 0.001), LDL (r = 0.271, p < 0.001), and triglycerides (r = 0.407, p < 0.001) and inversely associated with levels of HDL (r = 0.117, p = 0.001). Prevalence of dyslipidemia increased with duration of diabetes (p < 0.05). Hypertension was more prevalent in overweight and obese compared to normal-weight patients (40.6 and 65.6 vs. 25.6%, respectively, p < 0.001). Frequency of microvascular complications was higher among patients with dyslipidemia (27.2 vs. 18.8%, p = 0.005) and among those with hypertension (25.9 vs. 23.2%, p < 0.001). Conclusion. The frequency of cardiovascular risk factors is high in youth with T1D and associated with diabetes duration, obesity, and metabolic control.

Novel ambulatory glucose-sensing technology improves hypoglycemia detection and patient monitoring adherence in children and adolescents with type 1 diabetes

Purpose

Glucose monitoring [GM] is a mainstay of diabetes control and management. Improving glycemic control is essential to prevent microvascular complications. However, adherence to GM can be a challenge in children and adolescents. Detecting hypoglycemia is essential for its prevention and treatment. We aim to study the impact of the flash ambulatory glucose monitoring in detecting hypoglycemia and enhancing adherence in children and adolescents with type 1 diabetes.

Methods

The study is prospective involving 3 hospital visits. Children and adolescents with diabetes were enrolled in the study which involved a period on conventional glucose self-monitoring [glucometers] followed by a similar period of monitoring using the flash glucose monitoring device (FreeStyle Libre). Frequency of GM, duration and frequency of hypoglycemia were compared on conventional and the flash monitoring.

Results

75 subjects were studied. Age mean (range) was 11.9 years (2-19). Significant difference was seen in hypoglycemia detection between both testing devices. 68 (94%) and 65 (90%) patients detected nocturnal and diurnal hypoglycemia respectively on Flash monitoring compared to 12 (16.6%) and 30 (41%) on glucometer testing (p < 0.00). Mean (range) duration of hypoglycemia was 95 min (15-330). Statistically-significant difference was found between the frequency of GM on glucometer testing compared with Flash monitoring (2.87 and 11.6/day) (p < 0.001).

Conclusions

Flash monitoring is a useful tool to improve adherence to GM and detecting hypoglycemia [diurnal and nocturnal] in children and adolescents with type 1 diabetes.

The rate of hyperglycemia and ketosis with insulin degludec-based treatment compared with insulin detemir in pediatric patients with type 1 diabetes: An analysis of data from two randomized trials

BACKGROUND

Historically, data on the rate of hyperglycemia and ketosis have not been collected in clinical trials. However, it is clinically important to assess the rate of these events in children with type 1 diabetes (T1D). This question was addressed in two pediatric trials using insulin degludec (degludec).

OBJECTIVE

To assess the rate of hyperglycemia and ketosis in two-phase 3b trials investigating degludec (Study 1) and degludec with insulin aspart (IDegAsp [Study 2]) vs insulin detemir (IDet).

SUBJECTS

Patients (aged 1-17 years inclusive) with T1D treated with insulin for ≥3 months.

METHODS

Study 1: patients were randomized to degludec once daily (OD) or IDet OD/twice daily (BID) for 26 weeks, followed by a 26-week extension phase. Study 2: patients were randomized to IDegAsp OD or IDet OD/BID for 16 weeks. Bolus mealtime IAsp was included in both studies. In Study 1, hyperglycemia was recorded if plasma glucose (PG) was >11.1 mmol/L, with ketone measurement required with significant hyperglycemia (>14.0 mmol/L). In Study 2, hyperglycemia was recorded with PG >14.0 mmol/L where the subject looked/felt ill, with ketone measurement also required in these hyperglycemic patients. In this post hoc analysis, the hyperglycemia threshold was 14.0 mmol/L for uniformity.

RESULTS

Despite similar rates of hyperglycemia with degludec/IDegAsp compared with IDet, the rates of ketosis were lower with degludec/IDegAsp.

CONCLUSIONS

These trials, the first to systematically collect data on ketosis in pediatric patients with T1D, demonstrate the potential of degludec/IDegAsp to reduce rates of metabolic decompensation, compared with IDet.

Is there an optimal strategy for real-time continuous glucose monitoring in pediatrics? A 12-month French multi-center, prospective, controlled randomized trial (Start-In!)

AIM

To compare the efficacy of three strategies for real-time continuous glucose monitoring (RT-CGM) over 12 months in children and adolescents with type 1 diabetes.

METHODS

A French multicenter trial (NCT00949221) with a randomized, controlled, prospective, open, and parallel-group design was conducted. After 3 months of RT-CGM, patients were allocated to one of three groups: return to self-monitoring of blood glucose, continuous CGM (80% of the time), or discontinuous CGM (40% of the time). The primary outcome was hemoglobin A1c (HbA1c) levels from 3 to 12 months. The secondary outcomes were acute metabolic events, hypoglycemia, satisfaction with CGM and cost.

RESULTS

We included 151 subjects, aged 2 to 17 years, with a mean HbA1c level of 8.5% (SD0.7; 69 mmol/mol). The longitudinal change in HbA1c levels was similar in all three groups, at 3, 6, 9 and 12 months. The medical secondary endpoints did not differ between groups. The rate of severe hypoglycemia was significantly lower than that for the pretreatment year for the entire study population. Subjects reported consistent use and good tolerance of the device, regardless of age or insulin treatment. The use of full-time RT-CGM for 3 months costs the national medical insurance system €2629 per patient.

CONCLUSION

None of the three long-term RT-CGM strategies evaluated in pediatric type 1 diabetes was superior to the others in terms of HbA1c levels. CGM-use for 3 months decreased rates of severe hypoglycemia. Our results confirm the feasibility of long-term RT-CGM-use and the need to improve educational support for patients and caregivers.

Health care access and glycemic control in youth and young adults with type 1 and type 2 diabetes in South Carolina

Affordability and geographic accessibility are key health care access characteristics. We used data from 481 youth and young adults (YYA) with diabetes (389 type 1, 92 type 2) to understand the association between health care access and glycemic control as measured by HbA1c values. In multivariate models, YYA with state or federal health insurance had HbA1c percentage values 0.68 higher (P = 0.0025) than the privately insured, and those without insurance 1.34 higher (P < 0.0001). Not having a routine diabetes care provider was associated with a 0.51 higher HbA1c (P = 0.048) compared to having specialist care, but HbA1c did not differ significantly (P = 0.069) between primary vs specialty care. Distance to utilized provider was not associated with HbA1c among YYA with a provider (P = 0.11). These findings underscore the central role of health insurance and indicate a need to better understand the root causes of poorer glycemic control in YYA with state/federal insurance.

Variation of carbohydrate intake in diabetic children on carbohydrate counting

AIMS

Carbohydrate counting (CC) is a technique for managing diabetes particularly based on the counting of carbohydrates. It allows diabetic patients to vary their amount of carbohydrates from one meal to another by adjusting their insulin dose. The primary objective was to determine the variation of carbohydrate intake (CI) in children on CC.

METHOD

This was a prospective study conducted between 2014 and 2016. We collected the amount of carbohydrates eaten at each meal by 77 diabetic over a period of 28 days (i.e. 8068 data). We analyzed the number and percentage of significant CI variation rates from one day to another, both for the whole day and for each meal. The CI variation rate was deemed significant if it was greater than or equal to 30%.

RESULTS

The percentage of significant CI variation rates was 30% at the daily level, 34% for breakfast, 44% for lunch and dinner, and 53% for snack. The percentage of significant variation rates varied according to age, treatment and occurrence of events.

CONCLUSION

Children varied their CI significantly from one meal to another more than one in three times. CC offers flexibility and a better quality of life for children using this method.

Transition from paediatric to adult care: a qualitative study of the experiences of young adults with type 1 diabetes

AIM

The aim of the present study was to explore how young adults with type 1 diabetes (T1D) experienced the transition from paediatric to adult health care services.

DESIGN

A qualitative, explorative design was used.

METHODS

Eleven young adults with T1D receiving adult diabetes care at a hospital in western Norway participated in semi-structured interviews. Data were analysed using Interpretive Description, an inductive approach inspired by grounded theory, ethnography and phenomenology, and specifically designed to explore phenomena in clinical practice aiming to generate new knowledge and skills.

RESULTS

Four main themes regarding the adolescents' experiences of the transfer from paediatric to adult care emerged: (i) limited information about the transition; (ii) transition from frequent, thorough and personal follow-up to a less comprehensive and less personal follow-up; (iii) the importance of being seen as a whole person; (iv) limited expectations of how the health care services were organised.

CONCLUSIONS

The study showed that the existing routines for transfer between paediatric and adult care are not optimal. The participants expressed that they were not prepared for the dissimilarities in follow-up and were predominantly less pleased with the adult care follow-up.

RELEVANCE TO CLINICAL PRACTICE

The findings support a need for structured transition programmes, that is programmes that contribute to young adults with T1D receiving a safe and positive transition at an otherwise demanding life phase. Young peoples' individual needs for the transition to and follow-up in adult care may be promoted by an approach based on person-centred care.

Frequency and Characteristics of MODY 1 (HNF4A Mutation) and MODY 5 (HNF1B Mutation): Analysis From the DPV Database

OBJECTIVE

To characterize the initial presentation and clinical course of patients with hepatocyte nuclear factor (HNF) 4A‒ and HNF1B‒MODY in a multinational registry.

DESIGN, SETTING, AND PARTICIPANTS

Within the Diabetes Patienten Verlaufsdokumentation (DPV) registry, 44 patients with HNF4A- and 35 patients with HNF1B-MODY were characterized and compared with patients <20 years old with type 1 diabetes (T1D)/type 2 diabetes (T2D).

MAIN OUTCOME MEASURE

Clinical and laboratory parameters, therapy, metabolic control, and extrapancreatic symptoms in patients with HNF1B-MODY.

RESULTS

Patients with both MODY types were significantly older than patients with T1D at diagnosis (HNF4A, 13.8 years, and HNF1B, 13.5 years, vs T1D, 8.8 years; P < 0.0001). Mean C-peptide at diagnosis was higher for HNF4A-MODY than for T1D (1.8 vs 0.9 ng/mL; P < 0.01); 36.4% of patients with HNF4A-MODY and 65.7% of patients with HNF1B-MODY were treated with insulin, whereas 20.5% and 8.6% received oral antidiabetics only (P < 0.05 and P < 0.01 vs T2D). At the most recent visit, glycated hemoglobin levels were lower in HNF4A- and HNF1B-MODY (mean, 6.5% and 6.1%) than in T1D (7.9%; P < 0.0001). In 40% of patients with HNF1B-MODY, extrapancreatic symptoms were reported. Several clinical predictors previously described to differentiate between MODY and T1D or T2D were revalidated by logistic regression analyses in this cohort.

CONCLUSION

The DPV registry enabled us to precisely characterize phenotype and treatment in these two rare MODY types. Although phenotype of HNF4A- and HNF1B-MODY showed distinct differences from those of T1D and T2D, 38% of patients were initially misclassified as having T1D or T2D.

Association of diabetic ketoacidosis, severe hypoglycemia and glycemic control among children and young adults with type 1 diabetes mellitus treated with premixed versus basal-bolus insulin therapy

BACKGROUND

This study compared event rates of diabetic ketoacidosis (DKA) and severe hypoglycemia, as well as glycemic control, among children, adolescents, and young adults with type 1 diabetes mellitus (T1DM) receiving basal-bolus or premixed insulin therapy.

METHODS

A total of 825 individuals aged ≤ 20 years with T1DM, using either basal-bolus or premixed insulin regimens, were retrospectively recruited from 2001 to 2015. Rates of DKA after diagnosis, severe hypoglycemia, and the level of glycated hemoglobin A1c (HbA1c) improvement during the follow-up period were analyzed.

RESULTS

Of the 825 patients, 226 receiving a premixed regimen were matched to the same number of patients receiving a basal-bolus regimen. In the matched cohort, DKA (10.62% vs. 5.31%; p = 0.037) and severe hypoglycemic episodes (25.22% vs. 10.62%; p < 0.001) were significantly higher in patients receiving a premixed regimen than those receiving a basal-bolus regimen. The median reduction of HbA1c, compared to the treatment-naive level, was better with the basal-bolus regimen than with the premixed regimen in both matched (2.2 vs. 2.1; p = 0.034) and the entire (3.1 vs. 1.9; p < 0.001) cohorts. Regardless of insulin regimen, a higher HbA1c level was significantly linked to higher risk of DKA development (hazard ratio [HR] 1.35 per 1% increase; p < 0.001) once the HbA1c level was ≥7.5%.

CONCLUSIONS

A premixed insulin regimen may increase the DKA occurrence rate and severe hypoglycemic risk in children, adolescents, and young adults with TIDM, compared to a basal-bolus regimen. Tight glycemic control with HbA1c < 7.5% may prevent the increased risk of DKA.

Levels of type 1 diabetes care in children and adolescents for countries at varying resource levels

Optimal care for children and adolescents with type 1 diabetes is well described in guidelines, such as those of the International Society for Pediatric and Adolescent Diabetes. High-income countries can usually provide this, but the cost of this care is generally prohibitive for lower-income countries. Indeed, in most of these countries, very little care is provided by government health systems, resulting in high mortality, and high complications rates in those who do survive. As lower-income countries work toward establishing guidelines-based care, it is helpful to describe the levels of care that are potentially affordable, cost-effective, and result in substantially improved clinical outcomes. We have developed a levels of care concept with three tiers: "minimal care," "intermediate care," and "comprehensive (guidelines-based) care." Each tier contains levels, which describe insulin and blood glucose monitoring regimens, requirements for hemoglobin A1c (HbA1c) testing, complications screening, diabetes education, and multidisciplinary care. The literature provides various examples at each tier, including from countries where the life for a child and the changing diabetes in children programs have assisted local diabetes centres to introduce intermediate care. Intra-clinic mean HbA1c levels range from 12.0% to 14.0% (108-130 mmol/mol) for the most basic level of minimal care, 8.0% to 9.5% (64-80 mmol/mol) for intermediate care, and 6.9% to 8.5% (52-69 mmol/mol) for comprehensive care. Countries with sufficient resources should provide comprehensive care, working to ensure that it is accessible by all in need, and that resulting HbA1c levels correspond with international recommendations. All other countries should provide Intermediate care, while working toward the provision of comprehensive care.

Blood glucose meters and test strips: global market and challenges to access in low-resource settings

Blood glucose meters and test strips for self-monitoring of blood glucose (SMBG) are often inaccessible to, and infrequently used by, people with diabetes in countries with limited resources for health care. Supplies for measuring blood glucose can also be scarce in health facilities, despite being needed in a myriad of clinical settings at all levels of the health system. Numerous studies and international guidelines emphasise the value of SMBG in diabetes care, particularly in people with type 1 diabetes. In this Review, we assess global access to blood glucose meters and test strips, collating published information on cost, availability, system accuracy, competitive bidding, technological trends, and non-financial barriers. We also provide new information on global market share data and prices, taxes and tariffs, and product availability. Blood glucose meters and test strips should be viewed similarly to essential medicines, with issues of access prioritised by relevant international agencies. Efforts are needed to reduce tariffs and taxes and to create unified global system accuracy requirements and accountable post-marketing evaluations. Preferential pricing arrangements, pooled procurement, and best-purchasing practices could help to lower direct costs. SMBG supplies should also be included in national health insurance schemes. Enhanced diabetes education of health professionals and patients is crucial to ensure effective use of SMBG. Finally, as technology advances for people who can afford new interstitial fluid glucose monitoring systems, blood glucose meters and test strips must remain available and become more affordable in low-resource settings.

May gender influence the quality of life in children and adolescents with type 1 diabetes?

INTRODUCTION

Appropriate health-related quality of life (HRQOL) in children and adolescents with type 1 diabetes constitutes one of the most important factors that determine treatment effectiveness. There are numerous studies which tackle the issue of the relationship between HRQOL and various clinical and demographic factors, including gender. Therefore, the aim of the present study was to assess HRQOL and identify factors by which it may be affected, with particular emphasis on gender.

MATERIAL AND METHODS

The study group included 197 girls and boys (13.9±2.33 years old) with a history of type 1 diabetes (>1 year) treated with the use of insulin pumps. PedsQL Diabetes Module 3.0 questionnaire was used in the assessment of HRQOL. Multivariate linear regression with gender as a covariate was used to investigate the relationship between total PedsQL score and selected variables associated with patient characteristics, insulin dosage and the control of glycemia. Moreover, the presence of gender differences was verified in terms of variables which significantly affected HRQOL.

RESULTS

Significantly higher results were observed in boys as regards the total PedsQL score (70.8±11.91 vs 62.4±13.91; P<0.001) and individual subscales of the questionnaire (except "Worry"). Regression analysis demonstrated the presence of a significant negative relationship between HRQOL assessment and HbA1c concentrations, WHtR value and the frequency of hypoglycemic episodes. However, it was noted that better HRQOL was observed in boys than in girls, regardless of the quality of the metabolic control of diabetes, regular pattern of adipose tissue distribution and experiencing hyperglycemic episodes.

CONCLUSION

Female gender was an independent factor which adversely affected HRQOL. Other factors which negatively influenced HRQOL included poor metabolic control of diabetes, central distribution of adipose tissue and frequent episodes of hyperglycemia. It seems necessary to focus also on other factors that may potentially influence HRQOL of patients with type 1 diabetes.

Trajectories of Health-Related Quality of Life and HbA1c Values of Children and Adolescents With Diabetes Mellitus Type 1 Over 6 Months: A Longitudinal Observational Study

Introduction: To achieve optimized blood glucose concentrations (assessed by HbA1c) and high health-related quality of life (HRQL), children and adolescents with diabetes mellitus type 1 (T1DM) must follow strict disease management strategies. This study aims to investigate HRQL of children and adolescents with T1DM and its association with HbA1c values over the course of 6 months. Methods: Patients aged 7-17 years (n = 203) with T1DM provided HRQL data on a monthly basis. HRQL was measured using the Kids-CAT, a computer-adaptive test (CAT) comprising five generic HRQL domains. HbA1c concentrations were assessed at baseline, at 3 and 6 months. We explored the trajectory of HRQL at the domain level using linear mixed effects models. Further, we investigated the association between HRQL and HbA1c concentrations over time using path analysis models. Results: Children and adolescents with T1DM reported high scores across all HRQL domains over time. However, those with an HbA1c concentrations of >9.0% reported significantly lower scores in physical well-being and parent relations compared with those with an HbA1c concentration of <7.5%. Path analysis models revealed a minimal temporal relationship between HbA1c and HRQL, with a small negative impact of HbA1c on physical well-being, psychological well-being and parent relations. Conclusion: Although observed HRQL of young patients with T1DM was comparable to age-related German-speaking reference population over the course of 6 months, those with an HbA1c concentration >9.0% reported lower scores in selected HRQL domains. Thus, special attention should be drawn to HRQL of children and adolescents with higher HbA1c concentrations. The minimal relationship between HbA1c and HRQL indicates that the two therapy goals, i.e., achievement and maintenance of glycemic targets and high HRQL, should be considered and evaluated independently in clinical routine. Trial Registration: DRKS00006326 (German Clinical Trial Register), date of registration: August 1st, 2014.

Physiological factors influencing diabetes control in type 1 diabetes children with insulin pumps from diagnosis

BACKGROUND

The aim of this study was to identify the physiological factors influencing diabetes control in children with type 1 diabetes (T1D) using continuous subcutaneous insulin infusion (CSII) from diabetes diagnosis.

METHODS

This study focused on 163 children (81 boys) initiated with CSII within 2 weeks after T1D recognition and treated for at least 3 years. We analysed fasting C-peptide, GADA, ICA, IA2A, BMI z-score, total daily dose, and basal insulin. Patients were divided into groups according to their metabolic control: 7.5% > HbA1c ≥ 7.5% at the end of the study.

RESULTS

At the end of the follow-up, patients with HbA1c <7.5%, had a lower HbA1c level at diagnosis (11.7% vs 12.6%; P = 0.018), lower HbA1c level at both the first-year (6.7% vs 7.3%; P = 0.000) and the second-year (6.8% vs.7.7%; P = 0.000) follow-up, and a lower GADA level (P = 0.001). A multiple logistic regression analysis showed that HbA1c at diagnosis (P = 0.012), HbA1c at first year (P = 0.000), HbA1c at second year (P = 0.000), age at diagnosis (P = 0.047), GADA (P = 0.031), and basal insulin at third year (P = 0.032), influenced HbA1c <7.5% at the third year of follow-up. At the end of the study, 76% of patients started with CSII at the age <10 years and 49% of subjects initiated with CSII at the age ≥10 years achieved HbA1c ≤7.5%.

CONCLUSIONS

This study shows that for those who initiated CSII at T1D onset, younger age, less intense autoimmune process, a low HbA1c at recognition, and good diabetes control during the first year of treatment were associated with long-term optimal glycaemic control.

Personal and Clinical Predictors of Poor Metabolic Control in Children with Type 1 Diabetes in Jordan

BACKGROUND

Achieving adequate metabolic control in children with type 1 diabetes is important in slowing the progression of future microvascular and macrovascular complications, but still it is a universal challenge. We aim to investigate possible factors associated with poor metabolic outcomes in Jordan as an example of a country with limited resources.

METHODS

This is a retrospective chart review study of children with type 1 diabetes. Several clinical and personal characteristics were tested for association with metabolic control reflected by HbA1c levels. Linear logistic regression analysis was used to evaluate possible predictors of metabolic control. One-way ANOVA analysis was used to detect significant differences in HbA1c between categories.

RESULTS

Significant predictors of metabolic control were found. A one-year increase in age led to an increase in HbA1c by 0.053% (P = 0.044). A decline in HbA1c levels was predicted in children who have precise amount of carbohydrates or who are receiving insulin at school (-0.46% (P = 0.014) and -0.82% (P = 0.004), respectively). When family members other than mothers decided the insulin dose, the HbA1c level increased by 0.74% (P = 0.005).

CONCLUSION

Poor metabolic control was associated with age, dietary noncompliance, not receiving insulin at school, and absence of direct mother care. Our study is one of the few studies from Middle East evaluating predictors of metabolic control. Global research studies help in giving universal insight towards developing more effective multidisciplinary team approach for diabetes care and education.

Health-related quality of life of adolescents with type 1 diabetes in the context of resilience

BACKGROUND

Adolescents with type 1 diabetes (T1D) can be faced with deterioration in glycemic control (GC), reduced health-related quality of life (HRQoL), and other psychosocial problems. It is important to understand how the disease and its clinical conditions influence HRQoL and how adolescents are able to overcome the life adjustment difficulties.

OBJECTIVE

To assess HRQoL of adolescents with T1D from demographic, clinical, personal, and behavioral point of view.

SUBJECTS

A total of 229 adolescents with T1D (51.2% males) with a mean age of 15.35 (2.29) years old were recruited from three diabetes centers. The mean diabetes duration was 7.48 (3.87), the mean hemoglobin A1C (HbA1c) level was 10.3 (1.76) mmol/L.

METHODS

A multicenter quantitative correlational design study was applied to investigate the influence of sex, age, diabetes duration, GC expressed by HbA1c, intensive insulin regimen, physical activity (PA), resilience (RS), and socioeconomic background on HRQoL.

RESULTS

Presence of the diabetes symptoms and worry about the disease has negative impact on the patients' HRQoL. Stepwise multiple regression analyses indicated that insulin pump therapy, male sex, and higher level of RS were significantly related to an increase in HRQoL, whereas the higher level of PA, male sex, and better HRQoL was significantly related to positive change in RS. Patients treated with insulin pump therapy had significantly better HRQoL.

CONCLUSIONS

Significant association can be observed between HRQoL and RS. Supposedly, higher level of PA promotes higher level of RS that in turn helps increase HRQoL in adolescents with T1D. Treatment with insulin pump therapy also promotes better HRQoL.

Frequency of Self-Monitoring of Blood Glucose during the School Day Is Associated with the Optimal Glycemic Control among Korean Adolescents with Type 1 Diabetes

BACKGROUND

This study aimed to evaluate the relationship between the frequency of self-monitoring of blood glucose (SMBG) and glycosylated hemoglobin (HbA1c) levels among Korean adolescents with type 1 diabetes mellitus (T1DM). Factors affecting the SMBG frequency were analyzed in order to improve their glycemic control.

METHODS

Sixty-one adolescents aged 13 to 18 years with T1DM were included from one tertiary center. Clinical and biochemical variables were recorded. Factors associated with SMBG frequency were assessed using structured self-reported questionnaires.

RESULTS

Average total daily SMBG frequency was 3.8±2.1 and frequency during the school day was 1.3±1.2. The mean HbA1c level was 8.6%±1.4%. As the daily SMBG frequency increased, HbA1c levels declined (P=0.001). The adjusted odds of achieving the target HbA1c in participants who performed daily SMBG ≥5 significantly increased 9.87 folds (95% confidence interval [CI], 1.58 to 61.70) compared with those performed SMBG four times a day. In the subjects whose SMBG frequency <1/day during the school day, an 80% reduction in the adjusted odds ratio 0.2 (95% CI, 0.05 to 0.86) showed compared to the group with performing two SMBG measurements in the school setting. The number of SMBG testing performed at school was significantly high for individuals assisted by their friends (P=0.031) and for those who did SMBG in the classrooms (P=0.039).

CONCLUSION

Higher SMBG frequency was significantly associated with lower HbA1c in Korean adolescents with T1DM. It would be necessary to establish the school environments that can facilitate adequate glycemic control, including frequent SMBG.

Being mothers and fathers of a child with type 1 diabetes aged 1 to 7 years: a phenomenological study of parents' experiences

Purpose: The diagnosis of diabetes in pre-school children poses a number of unique challenges related to everyday responsibility, and the continuous need for supervision and caregiving. This may affect both the child’s and the parents’ perceived burden caused by the condition. The aim of the study was to explore the lived experience of being mothers and fathers of a child with type 1 diabetes aged 1 to 7 years.

Methods: The study is rooted in an interpretive phenomenological methodology as described by van Manen. In-depth interviews were carried out to collect data.

Findings. We were able to identify one essential theme across the interviews: Striving to live an ordinary family life, yet feeling and living very differently—with interrelated sub-themes: A life-changing situation, Always on guard, and Struggling to let go.

Conclusion: Parents described a profoundly changed situation, and they were indeed striving to live like a “normal” family. They were in need of support from health care professionals at the outpatient clinic, not only support and supervision in regard to practical tasks, but also concerning handling a changed life situation and emotional reactions, especially in the first year after diagnosis.

A systematic review of non-genetic predictors and genetic factors of glycated haemoglobin in type 1 diabetes one year after diagnosis

Type 1 diabetes (T1D) results from autoimmune destruction of the pancreatic βcells. Although all T1D patients require daily administration of exogenous insulin, their insulin requirement to achieve good glycaemic control may vary significantly. Glycated haemoglobin (HbA1c) level represents a stable indicator of glycaemic control and is a reliable predictor of long-term complications of T1D. The purpose of this article is to systematically review the role of non-genetic predictors and genetic factors of HbA1c level in T1D patients after the first year of T1D, to exclude the honeymoon period. A total of 1974 articles published since January 2011 were identified and 78 were finally included in the analysis of non-genetic predictors. For genetic factors, a total of 277 articles were identified and 14 were included. The most significantly associated factors with HbA1c level are demographic (age, ethnicity, and socioeconomic status), personal (family characteristics, parental care, psychological traits...) and features related to T1D (duration of T1D, adherence to treatment …). Only a few studies have searched for genetic factors influencing HbA1c level, most of which focused on candidate genes using classical genetic statistical methods, with generally limited power and incomplete adjustment for confounding factors and multiple testing. Our review shows the complexity of explaining HbA1c level variations, which involves numerous correlated predictors. Overall, our review underlines the lack of studies investigating jointly genetic and non-genetic factors and their interactions to better understand factors influencing glycaemic control for T1D patients.

Efficacy and safety of a fixed combination of insulin degludec/insulin aspart in children and adolescents with type 1 diabetes: A randomized trial

BACKGROUND

Insulin degludec/insulin aspart (IDegAsp) is a fixed soluble co-formulation of basal and bolus insulin.

OBJECTIVE

To evaluate efficacy and safety of IDegAsp in pediatric patients with type 1 diabetes (T1D).

SUBJECTS

Children and adolescents (aged 1 to <18 years) with T1D.

METHODS

A 16-week, phase 3b, treat-to-target, parallel-group, open-label, non-inferiority trial was conducted at 63 sites in 14 countries from October 2013 to November 2014. Patients were randomized 1:1 (age stratified: 1-<6 years; 6-<12 years; 12-<18 years) to IDegAsp once daily (OD) plus insulin aspart (IAsp) for remaining meals (IDegAsp + IAsp), or IDet OD or twice daily plus mealtime IAsp (IDet + IAsp). The primary end-point was HbA1c change from baseline at week 16.

RESULTS

A total of 362 participants were randomized to IDegAsp + IAsp (n = 182) or IDet + IAsp (n = 180). HbA1c decreased from baseline to week 16 by 0.3% in both groups (estimated treatment difference: -0.04%-points [-0.23; 0.15]_95%CI (-0.45 mmol/mol [-2.51; 1.60]_95%CI ), confirming non-inferiority. There were no significant differences between treatment groups in fasting or self-measured plasma glucose. Confirmed hypoglycemia rates did not significantly differ between groups. There was a significant reduction in basal and total insulin dose with IDegAsp + IAsp vs IDet + IAsp (post hoc analysis). Mean number of injections/day was 3.6 and 4.9 with IDegAsp + IAsp and IDet + IAsp, respectively (post hoc analysis). A non-significant higher rate of severe hypoglycemia was observed with IDegAsp + IAsp vs IDet + IAsp. The most frequent adverse events in both groups were hypoglycemia, headache, and nasopharyngitis.

CONCLUSIONS

IDegAsp + IAsp was non-inferior to IDet + IAsp regarding HbA1c, had similar hypoglycemia rates and required fewer injections.

Translation and validation of Pediatric Quality of Life Inventory™ 3.0 Diabetes Module (PedsQL™ 3.0 Diabetes Module) in Brazil-Portuguese language

OBJECTIVE

The aim of the present study was to create a translated version of the Pediatric Quality of Life Inventory™ 3.0 Diabetes Module (PedsQL™ 3.0 Diabetes Module) in Brazilian Portuguese that was conceptually equivalent to the original American English version and to linguistically validate it in a Brazilian pediatric population with type 1 diabetes mellitus and their parents or caregivers.

METHODS

The instrument was translated, back-translated, and then administered to 83 children/adolescents (5-18 years) with type 1 diabetes mellitus and their family members and to 25 parents/caregivers of patients aged between 2 and 4 years. The final translated version was tested for reliability by analyzing internal consistency, intraobserver (test-retest) reliability, and concurrent validity.

RESULTS

Cronbach's alpha coefficient for the total score of the questionnaires of children/adolescents (α=0.85) and their parents (α=0.82) was above the recommended minimum of 0.70 for group comparisons. Intraobserver reliability and concurrent validity exhibited a significant positive correlation (p<0.001), indicating the reliability of the translated instrument. A moderate but significant positive correlation (r=0.40; p<0.001) was demonstrated between the total scores of patient self-report and parent proxy-report scales. There was no significant correlation between glycated hemoglobin (HbA1c) levels and the respective scores in the questionnaires answered by patients and their parents/caregivers.

CONCLUSION

The analysis of the translated version of the PedsQL™ 3.0 Diabetes Module revealed adequate psychometric characteristics with respect to reliability and validity following administration to a sample of Brazilian children/adolescents with type 1 diabetes mellitus and their caregivers.

Interventions using pediatric diabetes registry data for quality improvement: A systematic review

BACKGROUND

Diabetes registries contain vast amounts of data that can be used for quality improvement (QI) and are foundational elements of learning health systems; infrastructure to share data, create knowledge rapidly and inform decisions to improve health outcomes. QI interventions using adult diabetes registries are associated with improved glycemic control, complication screening rates, and reduced hospitalizations; pediatric data are limited.

OBJECTIVE

To evaluate the effects of QI strategies that use pediatric diabetes registry data on care processes, organization of care, and patient outcomes.

METHODS

We searched MEDLINE, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials, Google, Google Scholar, Directory of Open Access Journals, and diabetes registry websites for studies that evaluated the impact of QI interventions on diabetes care processes, care organization, or patient outcomes, using pediatric diabetes registry data. Two reviewers independently assessed eligibility, extracted data and assessed the risk of bias.

RESULTS

Twelve studies were included. Most interventions targeted health-care providers and evaluated effects on patient outcomes. Five of nine studies that evaluated hemoglobin A1c found improvements of 0.26% to 0.85% (2.8-9.3 mmol/mol) while four found no difference. Many report positive effects on care processes or organization. Study data could not be combined because of variable study design and outcome measures. Included studies represent a minority of existing registries.

CONCLUSIONS

Pediatric diabetes registries are underused for QI and may facilitate improved care and outcomes. Existing vast amount of pediatric registry data could be used to foster the development of learning health systems and to improve diabetes care and outcomes.

Outcomes of using flash glucose monitoring technology by children and young people with type 1 diabetes in a single arm study

BACKGROUND AND OBJECTIVE

Outcomes of using flash glucose monitoring have been reported in adults. This trial evaluated use in children and teenagers with type 1 diabetes.

METHODS

Prospective, single arm, non-inferiority multicenter study to demonstrate equivalence of time in range (TIR [70-180 mg/dL]) by comparing 14-day masked sensor wear (baseline) with self-monitored blood glucose (SMBG) testing to the final 14-days of 8-week open-label system use for diabetes self-management including insulin dosing.

RESULTS

A total of 76 children and teenagers (46.1% male; age 10.3 ± 4.0 years, type 1 diabetes duration 5.4 ± 3.7 years; mean ± SD) from 10 sites participated. TIR improved significantly by 0.9 ± 2.8 h/d (P = 0.005) vs SMBG baseline. Time in hyperglycemia (>180 mg/dL) reduced by -1.2 ± 3.3 h/d (P = 0.004). HbA1c reduced by -0.4% (-4.4 mmol/mol), from 7.9 ± 1.0% (62.9 ± 11.2 mmol/mol) baseline to 7.5 ± 0.9% (58.5 ± 9.8 mmol/mol) study end (P < 0.0001) with reductions across all age-subgroups (4-6, 7-12 and 13-17 years). Time in hypoglycemia (<70 mg/dL) was unaffected. Throughout the treatment phase system utilization was 91% ± 9; sensor scanning was 12.9 ± 5.7/d with SMBG dropping to 1.6 ± 1.9 from 7.7 ± 2.5/d. Diabetes Treatment Satisfaction Questionnaire "Total Treatment Satisfaction" score improved for parents (P < 0.0001) and teenagers (P < 0.0001). No adverse events (n = 121) were associated with sensor accuracy, 42 participants experienced sensor insertion signs and symptoms. Three participants experienced three mild device-related (sensor wear) symptoms, resolving quickly (without treatment [n = 2], non-prescription antihistamines [n = 1]).

CONCLUSIONS

Children with diabetes improved glycemic control safely and effectively with short-term flash glucose monitoring compared to use of SMBG in a single arm study.

Non-adjunctive flash glucose monitoring system use during summer-camp in children with type 1 diabetes: The free-summer study

BACKGROUND

A factory-calibrated sensor for intermittently scanned continuous glucose monitoring (isCGM) is accurate and safe in children with type 1 diabetes (T1D). Data on isCGM effectiveness as a replacement for self-monitoring of blood glucose (SMBG) in this population is scarce.

OBJECTIVE

The aim of this study was to evaluate the non-adjunctive use of isCGM in children with T1D during 2 weeks in a challenging summer-camp setting.

METHODS

In this two-arm, parallel, randomized, outpatient clinical trial we enrolled 46 children (25 females, mean ± SD: age 11.1 ± 2.6 years, glycated hemoglobin (HbA1c) 7.4% ± 0.7%): 26 in the isCGM group were blinded for the SMBG and insulin dosing was isCGM-based, whereas 20 in the control group were blinded for isCGM and performed SMBG-based insulin dosing. The primary outcome of intention-to-treat analysis was between-group difference in the proportion of time within range 3.9 to 10 mmol/L (TIR).

RESULTS

There was no significant difference in TIR (3.9-10 mmol/L) between the two groups. In participants with suboptimal metabolic control (HbA1c > 7%) we observed a significant reduction in time spent above 10 mmol/L (P < 0.05) and an improvement in TIR (P = 0.05) in the isCGM group. No severe hypoglycemic events or serious adverse events occurred. Overall mean absolute relative difference (MARD) between isCGM and SMBG was 18.3%, with median absolute relative difference (ARD) of 8%. Consensus error grid analysis demonstrated 82.2% and 95.2% of results in zone A, and zone A + B, respectively.

CONCLUSION

The non-adjunctive use of isCGM was as safe and effective as SMBG, and reduced time spent in hyperglycemia in a sub-population of children with T1D with suboptimal glycemic control.

TRIAL REGISTRATION

NCT03182842.

Two-step recruitment process optimizes retention in FLEX clinical trial

Introduction

The Flexible Lifestyle Empowering Change Study (FLEX) is a multi-site randomized controlled trial to test the efficacy of an adaptive behavioral intervention to promote self-management and improve glycemic control for adolescents with type 1 diabetes mellitus. A two-step recruitment process was used to optimize study retention by facilitating informed decision-making regarding participation.

Methods

Those who expressed interest at first contact were given more detailed study information followed by telephone calls to the adolescents and their parents to answer questions and explore potential barriers to participation before making a decision regarding study enrollment.

Results

Of 694 eligible adolescents who were invited to participate, 397 (57.2%) expressed interest when initially contacted (Step 1). Upon completion of the follow-up telephone calls (Step 2), 276 (39.8%) still agreed to participate; and 258 (37.2%) enrolled and completed a baseline visit with a parent/guardian. Completion rates for measurement visits remained high throughout the study, with an end-of-study retention rate of 93.4%; and only 12 (4.7%) families withdrew from the study.

Conclusion

The two-step recruitment process encourages potential participants to thoughtfully evaluate their willingness to participate, as well as their ability to make a commitment to the full completion of study requirements. When demonstrating the efficacy of a randomized controlled trial, it may be preferable to accept lower recruitment rates in order to optimize retention rates. The additional time and effort required to implement this two-step process is worthwhile. With a high retention rate, we can be more confident that the outcomes of the randomized controlled trial actually reflect the impact of the intervention.