Hemoglobin A1c (HbA1c) changes over time among adolescent and young adult participants in the T1D exchange clinic registry

Strengths, Risk Factors, and Resilient Outcomes in Adolescents With Type 1 Diabetes: Results From Diabetes MILES Youth-Australia

OBJECTIVE

Despite the challenges of living with type 1 diabetes, many adolescents achieve "resilient outcomes": high engagement in self-management behaviors such as self-monitoring of blood glucose (SMBG), good quality of life (QOL), and within-target glycemic outcomes (HbA_1c). Adaptive diabetes-related behaviors (i.e., "strengths") are associated with resilient outcomes, yet the combination of risks and strengths in relation to resilient outcomes is unclear. The aim of this study was to investigate relations among diabetes strengths and resilient outcomes in the context of psychological and family risk factors.

RESEARCH DESIGN AND METHODS

A total of 471 Australian adolescents with type 1 diabetes (mean age 15.7 ± 1.9 years; diabetes duration 6.9 ± 4.2 years; 62% female; 53% using insulin pumps) completed a national cross-sectional survey about their diabetes-related strengths, risk factors (depressive/anxiety symptoms, family conflict), and resilient outcomes (SMBG frequency, general QOL, HbA_1c).

RESULTS

Greater diabetes strengths were significantly related to resilient outcomes: more frequent SMBG (r = 0.39), lower HbA_1c (r = -0.31), and higher general QOL (r = 0.50), as well as to lower risks: fewer depressive (r = -0.45) and anxiety (r = -0.40) symptoms and less conflict (r = 0.28). In multivariate regressions, diabetes strengths consistently related to all resilient outcomes beyond significant risk factors.

CONCLUSIONS

In a large sample of Australian adolescents, diabetes strengths were strongly related to key resilient outcomes, even in the presence of well-documented psychological and family risk factors. More research is needed to determine whether strengths reduce or buffer other risks. Given the associations with self-management, HbA_1c, and general QOL, monitoring and enhancing diabetes strengths may support resilience promotion during a vulnerable developmental period.

Incidence Trends of Type 1 and Type 2 Diabetes among Youths, 2002-2012

BACKGROUND

Diagnoses of type 1 and type 2 diabetes in youths present a substantial clinical and public health burden. The prevalence of these diseases increased in the 2001-2009 period, but data on recent incidence trends are lacking.

METHODS

We ascertained cases of type 1 and type 2 diabetes mellitus at five study centers in the United States. Denominators (4.9 million youths annually) were obtained from the U.S. Census or health-plan member counts. After the calculation of annual incidence rates for the 2002-2012 period, we analyzed trends using generalized autoregressive moving-average models with 2-year moving averages.

RESULTS

A total of 11,245 youths with type 1 diabetes (0 to 19 years of age) and 2846 with type 2 diabetes (10 to 19 years of age) were identified. Overall unadjusted estimated incidence rates of type 1 diabetes increased by 1.4% annually (from 19.5 cases per 100,000 youths per year in 2002-2003 to 21.7 cases per 100,000 youths per year in 2011-2012, P=0.03). In adjusted pairwise comparisons, the annual rate of increase was greater among Hispanics than among non-Hispanic whites (4.2% vs. 1.2%, P<0.001). Overall unadjusted incidence rates of type 2 diabetes increased by 7.1% annually (from 9.0 cases per 100,000 youths per year in 2002-2003 to 12.5 cases per 100,000 youths per year in 2011-2012, P<0.001 for trend across race or ethnic group, sex, and age subgroups). Adjusted pairwise comparisons showed that the relative annual increase in the incidence of type 2 diabetes among non-Hispanic whites (0.6%) was lower than that among non-Hispanic blacks, Asians or Pacific Islanders, and Native Americans (P<0.05 for all comparisons) and that the annual rate of increase among Hispanics differed significantly from that among Native Americans (3.1% vs. 8.9%, P=0.01). After adjustment for age, sex, and race or ethnic group, the relative annual increase in the incidence of type 1 diabetes was 1.8% (P<0.001) and that of type 2 diabetes was 4.8% (P<0.001).

CONCLUSIONS

The incidences of both type 1 and type 2 diabetes among youths increased significantly in the 2002-2012 period, particularly among youths of minority racial and ethnic groups. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and the Centers for Disease Control and Prevention.).

Longitudinal Trajectories of Metabolic Control From Childhood to Young Adulthood in Type 1 Diabetes From a Large German/Austrian Registry: A Group-Based Modeling Approach

OBJECTIVE

Worsening of glycemic control in type 1 diabetes during puberty is a common observation. However, HbA_1c remains stable or even improves for some youths. The aim is to identify distinct patterns of glycemic control in type 1 diabetes from childhood to young adulthood.

RESEARCH DESIGN AND METHODS

A total of 6,433 patients with type 1 diabetes were selected from the prospective, multicenter diabetes patient registry Diabetes-Patienten-Verlaufsdokumentation (DPV) (follow-up from age 8 to 19 years, baseline diabetes duration ≥2 years, HbA_1c aggregated per year of life). We used latent class growth modeling as the trajectory approach to determine distinct subgroups following a similar trajectory for HbA_1c over time.

RESULTS

Five distinct longitudinal trajectories of HbA_1c were determined, comprising group 1 = 40%, group 2 = 27%, group 3 = 15%, group 4 = 13%, and group 5 = 5% of patients. Groups 1-3 indicated stable glycemic control at different HbA_1c levels. At baseline, similar HbA_1c was observed in group 1 and group 4, but HbA_1c deteriorated in group 4 from age 8 to 19 years. Similar patterns were present in group 3 and group 5. We observed differences in self-monitoring of blood glucose, insulin therapy, daily insulin dose, physical activity, BMI SD score, body-height SD score, and migration background across all HbA_1c trajectories (all P ≤ 0.001). No sex differences were present. Comparing groups with similar initial HbA_1c but different patterns, groups with higher HbA_1c increase were characterized by lower frequency of self-monitoring of blood glucose and physical activity and reduced height (all P < 0.01).

CONCLUSIONS

Using a trajectory approach, we determined five distinct longitudinal patterns of glycemic control from childhood to early adulthood. Diabetes self-care, treatment differences, and demographics were related to different HbA_1c courses.

Iowa Gambling Task Performance Prospectively Predicts Changes in Glycemic Control among Adolescents with Type 1 Diabetes

OBJECTIVES

Good glycemic control is an important goal of diabetes management. Late adolescents with type 1 diabetes (T1D) are at risk for poor glycemic control as they move into young adulthood. For a subset of these patients, this dysregulation is extreme, placing them at risk for life-threatening health complications and permanent cognitive declines. The present study examined whether deficiency in emotional decision making (as measured by the Iowa Gambling Task; IGT) among teens with T1D may represent a neurocognitive risk factor for subsequent glycemic dysregulation.

METHODS

As part of a larger longitudinal study, a total of 241 high-school seniors (147 females, 94 males) diagnosed with T1D underwent baseline assessment that included the IGT. Glycated hemoglobin (HbA1c), which reflects glycemic control over the course of the past 2 to 3 months, was also assessed at baseline. Of the 241,189 (127 females, 62 males, mean age=17.76, mean HbA1c=8.11) completed HbA1c measurement 1 year later.

RESULTS

Baseline IGT performance in the impaired range (per norms) was associated with greater dysregulation in glycemic control 1 year later, as evidenced by an average increase in HbA1c of 2%. Those with normal IGT scores (per norms) exhibited a more moderate increase in glycemic control, with an HbA1c increase of 0.7%. Several IGT scoring approaches were compared, showing that the total scores collapsed across all trials was most sensitive to change in glycemic control.

CONCLUSIONS

IGT assessment offers promise as a tool for identifying late adolescents at increased risk for glycemic dysregulation. (JINS, 2017, 23, 204-213).

Components of Interventions That Improve Transitions to Adult Care for Adolescents With Type 1 Diabetes

Adolescents with type 1 diabetes struggle with glycemic control with decline further exacerbated by transfer from pediatric to adult care. The purpose of this systematic review/meta-analysis was to examine which components of transition programs are effective in improving outcomes following transfer. We searched six databases for studies that assessed the efficacy of a transition program on diabetes outcomes. Studies reporting hemoglobin A1c (HbA1c) or its change for the intervention versus control group pretransition and posttransition were pooled using a random effects meta-analysis model. Of 4,689 studies identified, 18 (1 randomized control trial, 6 quasi-experimental, 1 prospective, and 10 retrospective cohort) met inclusion criteria. Findings represent data from 3,382 youth with type 1 diabetes (52% male, age 16-23 years) undergoing transition. Programs varied and included transition coordinators (n = 7), transition clinics (n = 10), and group education meetings (n = 5). Average age of transfer was 17.7 years. All but one study reported improvement/maintenance of HbA1c posttransition. However, pooling data from four studies with a control group (418 youth), there were no differences in HbA1c at 12 months (-.11 [95% confidence interval: -.31, .08]). Of other outcomes studied (clinic attendance [n = 12], severe hypoglycemia [n = 8], and diabetic ketoacidosis [n = 7]), transition programs showed greatest consistency in reducing diabetic ketoacidosis episodes. Findings suggest that transition interventions may be effective in maintaining glycemic control and reducing diabetic ketoacidosis episodes posttransition. Further research is needed to determine which program types are most effective.

Improving the transition from pediatric to adult diabetes care: the pediatric care provider's perspective in Quebec, Canada

OBJECTIVES

The transition from pediatric to adult care is a high-risk period for the emerging adult with diabetes. We aimed to determine adequacy of pediatric transition care structures and explore the pediatric diabetes care provider's perceptions of transition care.

RESEARCH DESIGN AND METHODS

In-depth interviews with pediatric diabetes care providers from 12 diabetes centers in Quebec were conducted. We queried alignment with Got Transition's six core elements of healthcare transition, experiences, and barriers to transition care. Interview transcripts were reviewed for themes.

RESULTS

Three centers (25%) reported having any elements of formal and structured transition care preparation and planning. When referrals were within center (n=8), pediatric providers perceived that transition was smoother; information sharing relied heavily on verbal communication rather than documented medical summaries. Barriers included lack of adult providers, less flexibility in adult care scheduling, patient struggles with multiple new adult responsibilities, and insufficient understanding by adult providers of these challenges. There was a perception that the quality of pediatric care was better than adult care. Moving out of the pediatric care geographical region appeared to increase risk for poor follow-up. Patient satisfaction and regular follow-up in adult care were thought to be good measures of transition success. Programs that included overlap between pediatric and adult care were perceived as ideal.

CONCLUSIONS

Important gaps in transition care practices persist. Efforts should focus on improving education in transition practices for pediatric care providers and establishing formal transition policies and structures at the institutional level.

Incidence and Mortality Rates and Clinical Characteristics of Type 1 Diabetes among Children and Young Adults in Cochabamba, Bolivia

OBJECTIVES

To determine incidence, mortality, and clinical status of youth with diabetes at the Centro Vivir con Diabetes, Cochabamba, Bolivia, with support from International Diabetes Federation Life for a Child Program.

METHODS

Incidence/mortality data analysis of all cases (<25 year (y)) diagnosed January 2005-February 2017 and cross-sectional data (December 2015).

RESULTS

Over 12.2 years, 144 cases with type 1 diabetes (T1D) were diagnosed; 43.1% were male. Diagnosis age was 0.3-22.2 y; peak was 11-12 y. 11.1% were <5 y; 29.2%, 5-<10 y; 43.1%, 10-<15 y; 13.2%, 15-<20 y; and 3.5%, 20-<25 y. The youngest is being investigated for monogenic diabetes. Measured incidence in Cercado Province (Cochabamba Department) was 2.2/100,000 children < 15 y/y, with ≈80% ascertainment, giving total incidence of 2.7/100,000 children < 15 y/y. Two had died. Crude mortality rate was 2.3/1000 patient years. Clinical data on 141 cases <35 y: mean/median HbA1c was 8.5/8.2% (69/62 mmol/mol), levels higher in adolescents. Three were on renal replacement therapy; four others had substantial renal impairment. Elevated BMI, triglycerides, and cholesterol were common: 19.1%, 18.3%, and 39.1%, respectively.

CONCLUSIONS

Bolivia has low T1D incidence. Reasonable glycemic control is being achieved despite limited resources; however, some have serious complications and adverse cardiovascular risk factor profiles. Further attention is needed for complications.

Surgical research using national databases

Recent changes in healthcare and advances in technology have increased the use of large-volume national databases in surgical research. These databases have been used to develop perioperative risk stratification tools, assess postoperative complications, calculate costs, and investigate numerous other topics across multiple surgical specialties. The results of these studies contain variable information but are subject to unique limitations. The use of large-volume national databases is increasing in popularity, and thorough understanding of these databases will allow for a more sophisticated and better educated interpretation of studies that utilize such databases. This review will highlight the composition, strengths, and weaknesses of commonly used national databases in surgical research.

Insulin pump therapy in children with type 1 diabetes: analysis of data from the SWEET registry

BACKGROUND

Intensified insulin delivery using multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII) is recommended in children with type 1 diabetes (T1D) to achieve good metabolic control.

OBJECTIVE

To examine the frequency of pump usage in T1D children treated in SWEET (Better control in Paediatric and Adolescent diabeteS: Working to crEate CEnTers of Reference) centers and to compare metabolic control between patients treated with CSII vs MDI.

METHODS

This study included 16 570 T1D children participating in the SWEET prospective, multicenter, standardized diabetes patient registry. Datasets were aggregated over the most recent year of treatment for each patient. Data were collected until March 2016. To assess the organization of pump therapy a survey was carried out.

RESULTS

Overall, 44.4% of T1D children were treated with CSII. The proportion of patients with pump usage varied between centers and decreased with increasing age compared with children treated with MDI. In a logistic regression analysis adjusting for age, gender and diabetes duration, the use of pump was associated with both: center size [odd ratio 1.51 (1.47-1.55), P < .0001) and the diabetes-related expenditure per capita [odd ratio 1.55 (1.49-1.61), P < .0001]. Linear regression analysis, adjusted for age, gender, and diabetes duration showed that both HbA1c and daily insulin dose (U/kg/d) remained decreased in children treated with CSII compared to MDI (P < .0001).

CONCLUSIONS

Insulin pump therapy is offered by most Sweet centers. The differences between centers affect the frequency of use of modern technology. Despite the heterogeneity of centers, T1D children achieve relatively good metabolic control, especially those treated with insulin pumps and those of younger age.

Diabetes Control and Adherence in Adolescence

Type 1 diabetes is a chronic disease that can lead to severe complications if poorly controlled. Adolescents are particularly vulnerable to worsening diabetes control due to changes in physiology, family dynamics, and social interactions. Good diabetes control requires following a regimen of frequent blood glucose checks, accurate carbohydrate counts, and compliance with insulin administration. Patients who are challenged in controlling their diabetes do tend to respond to behavioral interventions; however, the effect of the intervention wanes over time. Using technology to provide interventions has shown promise in terms of improving compliance. Positive family support and adequate knowledge of the developmental stages is important to ensure a successful transition from childhood to adolescence. Providers should also incorporate a structured transition from adolescent to adult diabetes care. [Pediatr Ann. 2016;45(9):e327-e331.].

Technology Use in Transition-Age Patients With Type 1 Diabetes: Reality and Promises

Youth with chronic illnesses have the greatest risk for a decline in their health management during transition-age. Because of this demonstrated and well-known issue, research has focused on how to improve the transition of care process. Despite the increasing number of technological devices on the market and the advances in telemedicine modalities available to patients with type 1 diabetes (T1D), the utilization of technology is still suboptimal among patients of transition-age (ages 13-25). This article reviews the available resources, patterns of use in transition-age youth, and explores opportunities to advance technology use in transitioning patients with T1D from pediatric to adult care.

Type 1 diabetes: addressing the transition from pediatric to adult-oriented health care

Adolescents and young adults with type 1 diabetes are at risk for poor health outcomes, including poor glycemic control, acute and chronic complications, and emergency department admissions. During this developmental period, adolescent and young adult patients also experience significant changes in living situation, education, and/or health care delivery, including transferring from pediatric to adult health care. In recent years, professional and advocacy organizations have proposed expert guidelines to improve the process of preparation for and transition to adult-oriented health care. However, challenges remain and evidence-based practices for preparing youth for adult health care are still emerging. Qualitative research suggests that adolescent and young adult patients rely on health care providers to guide them through the transition process and appreciate a gradual approach to preparing for adult-oriented health care, keeping parents in supportive roles into young adulthood. Patients also benefit from specific referrals and contact information for adult care providers. Promising models of transition care include provision of transition navigators, attendance at a young adult bridge clinic, or joint visits with pediatric and adult care providers. However, much of this research is in its early stages, and more rigorous trials need to be conducted to evaluate health outcomes during transition into adult health care. The purpose of this review is to provide an overview of the transition process, patient and health care provider perceptions of transition care, and emerging evidence of successful models of care for engagement in adult-oriented health care. Recommendations and resources for health care providers are also presented.

Health Care Transition in Young Adults With Type 1 Diabetes: Perspectives of Adult Endocrinologists in the U.S

OBJECTIVE

Young adults with type 1 diabetes transitioning from pediatric to adult care are at risk for adverse outcomes. Our objective was to describe experiences, resources, and barriers reported by a national sample of adult endocrinologists receiving and caring for young adults with type 1 diabetes.

RESEARCH DESIGN AND METHODS

We fielded an electronic survey to adult endocrinologists with a valid e-mail address identified through the American Medical Association Physician Masterfile.

RESULTS

We received responses from 536 of 4,214 endocrinologists (response rate 13%); 418 surveys met the eligibility criteria. Respondents (57% male, 79% Caucasian) represented 47 states; 64% had been practicing >10 years and 42% worked at an academic center. Only 36% of respondents reported often/always reviewing pediatric records and 11% reported receiving summaries for transitioning young adults with type 1 diabetes, although >70% felt that these activities were important for patient care. While most respondents reported easy access to diabetes educators (94%) and dietitians (95%), fewer (42%) reported access to mental health professionals, especially in nonacademic settings. Controlling for practice setting and experience, endocrinologists without easy access to mental health professionals were more likely to report barriers to diabetes management for young adults with depression (odds ratio [OR] 5.3; 95% CI 3.4, 8.2), substance abuse (OR 3.5; 95% CI 2.2, 5.6), and eating disorders (OR 2.5; 95% CI 1.6, 3.8).

CONCLUSIONS

Our findings underscore the need for enhanced information transfer between pediatric and adult providers and increased mental health referral access for young adults with diabetes post-transition.

Challenges and Opportunities in the Management of Cardiovascular Risk Factors in Youth With Type 1 Diabetes: Lifestyle and Beyond

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in persons with type 1 diabetes (T1D). Specific risk factors associated with diabetes, such as hyperglycemia and kidney disease, have been demonstrated to increase the incidence and progression of CVD. Nevertheless, few data exist on the effects of traditional risk factors such as dyslipidemia, obesity, and hypertension on CVD risk in youth with T1D. Improvements in understanding and approaches to the evaluation and management of CVD risk factors, specifically for young persons with T1D, are desirable. Recent advances in noninvasive techniques to detect early vascular damage, such as the evaluation of endothelial dysfunction and aortic or carotid intima-media thickness, provide new tools to evaluate the progression of CVD in childhood. In the present review, current CVD risk factor management, challenges, and potential therapeutic interventions in youth with T1D are described.