Fear of Hypoglycemia in Children and Adolescents and Their Parents with Type 1 Diabetes

Fear of hypoglycemia relates to glycemic levels during and after real-world physical activity in adolescents with type 1 diabetes

BACKGROUND

We explore the association between hypoglycaemia fear (FH) and glycaemia during and after exercise sessions in a large sample of physically active youth with type 1 diabetes (T1D).

METHODS

We used data from the Type 1 Diabetes Exercise Initiative Paediatric (T1DEXIP) Study. Youth self-reported on FH using the Hypoglycaemia Fear Survey-Child (HFS-C). They used a smart phone application to self-report food intake and insulin dosing (multiple daily injection only). We collected pump and continuous glucose monitoring data directly from the device.

RESULTS

Our sample included n = 251 youth (mean age: 14 ± 2 years, 55% closed loop pump; 42% women). Youth reporting higher HFS-C Total and Helplessness/Worry scores (HFS-C subscale) had slightly fewer competitive and fewer high intensity exercise events compared to youth with lower HFS-C Total and Helplessness/Worry scores. Youth reporting the highest Maintain High Blood Glucose scores (HFS-C subscale) had the lowest percent glucose time in range, higher mean glucose levels, and higher percent time above range during exercise. Youth reporting the highest Maintain High Blood Glucose scores also tended to have higher mean glucose levels post-exercise and a smaller drop in glucose during exercise.

CONCLUSION

FH relates to glycaemia during and after exercise in adolescents with T1D and may signal an inclination for some youth to engage in avoidance behaviours to reduce their vulnerability to exercise-induced hypoglycaemia.

Parent Feedback on the Reducing Emotional Distress for Childhood Hypoglycemia in Parents (REDCHiP) Intervention: A Qualitative Analysis

OBJECTIVES

Severe hypoglycemia is more common among young children with type 1 diabetes mellitus (T1DM) than older youth, and parents report significant hypoglycemia fear (HF). Parents experiencing HF describe constant and extreme worry about the occurrence of hypoglycemia and may engage in potentially risky behaviors to avoid hypoglycemia. Our team developed and tested a behavioral intervention, Reducing Emotional Distress for Childhood Hypoglycemia in Parents (REDCHiP), to decrease HF in parents of young children with T1DM. Here, we qualitatively analyzed parent feedback to refine and optimize future intervention iterations.

METHODS

The randomized pilot study included parents (n = 73) of young children with T1DM who participated in the 10-session video-based intervention. We qualitatively analyzed 21 recordings of the final intervention session, where parents provided feedback about intervention content. Trained coders independently reviewed each session. The frequency of parent quotes regarding active REDCHiP treatment components were calculated.

RESULTS

The coded themes reflected active treatment components [viz., Use of Cognitive Behavioral Therapy (CBT) Skills, Coping, Behavioral Parenting Strategies]. Also, two secondary process codes were identified: Appreciate REDCHiP Content and Challenges in Applying REDCHiP Strategies. Parents provided examples of skills or concepts they applied from REDCHiP, the challenges they encountered, and if they planned to apply these skills in the future.

CONCLUSIONS

A qualitative analysis provided insight into parent perceptions of the active treatment components within the REDCHiP intervention, their acceptability, and parents' intention to apply REDCHiP skills/concepts within daily T1DM cares. Future iterations of the intervention that trial alternative formats (i.e., individual vs. group and asynchronous vs. telehealth) may increase accessibility and scalability.

Towards standardization of person-reported outcomes (PROs) in pediatric diabetes research: A consensus report

BACKGROUND

Diabetes ranks among the most common chronic conditions in childhood and adolescence. It is unique among chronic conditions, in that clinical outcomes are intimately tied to how the child or adolescent living with diabetes and their parents or carers react to and implement good clinical practice guidance. It is widely recognized that the individual's perspective about the impact of trying to manage the disease together with the burden of self-management should be addressed to achieve optimal health outcomes. Standardized, rigorous assessment of behavioural and mental health outcomes is crucial to aid understanding of person-reported outcomes alongside, and in interaction with, physical health outcomes. Whilst tempting to conceptualize person-reported outcomes as a focus on perceived quality of life, the reality is that health-related quality of life is multi-dimensional and covers indicators of physical or functional health status, psychological well-being and social well- being.

METHODS

In this context, this Consensus Statement has been developed by a collection of experts in diabetes to summarize the central themes and lessons derived in the assessment and use of person-reported outcome measures in relation to children and adolescents and their parents/carers, helping to provide a platform for future standardization of these measures for research studies and routine clinical use.

RESULTS

This consensus statement provides an exploration of person-reported outcomes and how to routinely assess and incorporate into clincial research.

A reinforcement learning approach to effective forecasting of pediatric hypoglycemia in diabetes I patients using an extended de Bruijn graph

Pediatric diabetes I is an endemic and an especially difficult disease; indeed, at this point, there does not exist a cure, but only careful management that relies on anticipating hypoglycemia. The changing physiology of children producing unique blood glucose signatures, coupled with inconsistent activities, e.g., playing, eating, napping, makes "forecasting" elusive. While work has been done for adult diabetes I, this does not successfully translate for children. In the work presented here, we adopt a reinforcement approach by leveraging the de Bruijn graph that has had success in detecting patterns in sequences of symbols-most notably, genomics and proteomics. We translate a continuous signal of blood glucose levels into an alphabet that then can be used to build a de Bruijn, with some extensions, to determine blood glucose states. The graph allows us to "tune" its efficacy by computationally ignoring edges that provide either no information or are not related to entering a hypoglycemic episode. We can then use paths in the graph to anticipate hypoglycemia in advance of about 30 minutes sufficient for a clinical setting and additionally find actionable rules that accurate and effective. All the code developed for this study can be found at: https://github.com/KurbanIntelligenceLab/dBG-Hypoglycemia-Forecast .

Fear of hypoglycemia and sleep in children with type 1 diabetes and their parents

Aims

To compare impact of pump treatment and continuous glucose monitoring (CGM) with predictive low glucose suspend (SmartGuard) or user initiated CGM (iscCGM) on sleep and hypoglycemia fear in children with type 1 Diabetes and parents.

Methods

Secondary analysis of data from 5 weeks pump treatment with iscCGM (A) or SmartGuard (B) open label, single center, randomized cross-over study was performed. At baseline and end of treatment arms, sleep and fear of hypoglycemia were evaluated using ActiGraph and questionnaires.

Results

31 children (6-14 years, male: 50%) and 30 parents (28-55 years) participated. Total sleep minutes did not differ significantly for children (B vs. A: -9.27; 95% CI [-24.88; 6.34]; p 0.26) or parents (B vs. A: 5.49; 95% CI [-8.79; 19.77]; p 0.46). Neither daytime sleepiness nor hypoglycemia fear in children or parents differed significantly between the systems. Neither group met recommended sleep criteria.

Conclusion

Lack of sleep and fear of hypoglycemia remain a major burden for children with diabetes and their parents. Whilst no significant differences between the systems were found, future technology should consider psychosocial impacts of diabetes and related technologies on children and parents' lived experience to ensure parity of esteem between physical and mental health outcomes.

Clinical Trial Registration

www.ClinicalTrials.gov, identifier NCT03103867.

Flash glucose monitoring system help reduce the frequency of hypoglycemia and hypoglycemic fear behavior in type 1 diabetes patients

Objective

Hypoglycemia represents a serious acute complication in individuals with type 1 diabetes mellitus (T1DM). In order to more effectively identify and discriminate the occurrence of hypoglycemic events in patients with T1DM, this study aims to evaluate the impact of two distinct glucose monitoring systems-Flash Glucose Monitoring (FGM) and Continuous Glucose Monitoring (CGM)-on the management of blood glucose levels and the emotional responses associated with hypoglycemic episodes in individuals with T1DM.

Method

In this study, a total of 113 patients with type 1 diabetes mellitus were enrolled and allocated to two groups for the implementation of Glucose Monitoring Systems (GMS). The groups consisted of the FreeStyle Libre group (FGM, n=56) and the ipro2 group (CGM, n=57). Participants in both groups utilized GMS at least biannually and completed a set of three questionnaires: the Diabetes Monitoring and Treatment Satisfaction Questionnaire (DMTSQ), the Diabetes Specific Quality of Life (DQOL), and the Chinese Version of the Hypoglycemia Fear Survey II (CFHSII). Clinical data, CGM metrics, and questionnaire scores were collected at the initial visit and after a one-year follow-up period.

Results

The glucose coefficient of variation (GCV) and the standard deviation of blood glucose (SDBG) were independently associated with Time Below Range (TBR). Specifically, GCV could predict TBR ≥12%, with a cut-off point of 40.55. This yielded a specificity of 88.10% and a sensitivity of 68.18% in the overall patient population. For the FreeStyle Libre group and the iPro2 group, the cut-off points were 38.69 and 40.55, respectively, with specificities of 0.74 and 0.92, and sensitivities of 0.73 and 0.86, respectively. In the FreeStyle Libre group, where the frequency of use was greater than or equal to five times per year, the hypoglycemic episodes (time/month) and CHFSII-B scores were significantly reduced at follow-up compared to baseline (7.80 ± 10.25 vs 13.95 ± 14.87; 27.37 ± 11.05 vs 38.90 ± 21.61, respectively, all P <0.05).

Conclusion

The utilization of multiple Flash Glucose Monitoring (FGM) implementations proved to be valuable in discriminating the occurrence of hypoglycemia and mitigating the fear of hypoglycemic episodes in patients with type 1 diabetes. Within the parameters of Glucose Monitoring Systems (GMS), the glucose glycemic variability (GCV) was identified as a predictive factor for the risk of severe hypoglycemia (TBR > 12%). The optimal cut-off point for GCV was determined to be 40.55.

Exploring Symptom Management Experiences Among College Students With Type 1 Diabetes Mellitus Using a Theoretical Framework: A Qualitative Study

PURPOSE

The purpose of this study was to explore symptom management experiences among college students with type 1 diabetes mellitus (T1DM). Limited qualitative data using a theoretical framework exist that explore the self-care behavior processes for symptom management.

METHODS

A qualitative approach was used for this study. The middle-range theory of self care of chronic illness served as a framework for data collection and analysis procedures. Data collection included distributing a survey to collect participants' demographic and sociodemographic data and utilizing a semi-structured interview guide to conduct one-on-one interviews with 31 participants. Interviews occurred via Zoom (n = 28) and in person (n = 3). Interview transcripts were uploaded in NVivo for data management. The research team created a codebook using theoretical constructs to assist with thematic analysis. Data are representative of a sample whose characteristics include undergraduate students ages 18 to 23 living with T1DM for 2 years or more who attended large, public, 4-year universities located in the southeastern United States.

RESULTS

Three main themes were created using theoretical constructs: symptom detection experiences, symptom interpretation experiences, and symptom response experiences. Two subthemes were identified for each theme. Participants engaged in symptom management for blood glucose regulation through detecting changes in their blood glucose physiologically and via technology. Additionally, symptom interpretation involved analyzing blood glucose trends and determining common causes of blood glucose changes. Symptom response included immediately addressing hypoglycemia but delayed responses addressing hyperglycemia.

CONCLUSIONS

Challenges were present responding to hypoglycemia; therefore, additional research is warranted to improve symptom response skills.

Effectiveness of switching from first-generation basal insulin to Glargine 300 U/mL in children and adolescents with type 1 diabetes: results from the ISPED CARD database

AIMS

Glargine 300 U/mL (Gla-300) has been recently approved for use in children and adolescents with type 1 diabetes (T1D). However, real-world effectiveness data are scarce, and aim of this analysis was to assess clinical outcomes in young patients with T1D switching from 1st generation basal insulin (1BI) to Gla-300.

METHODS

ISPED CARD is a retrospective, multicenter study, based on data anonymously extracted from Electronic Medical Records. The study involved a network of 20 pediatric diabetes centers. Data on all patients aged < 18 years with T1D switching from 1BI to Gla-300 were analyzed to assess clinical characteristics at the switch and changes after 6 and 12 months in glycated hemoglobin (HbA1c), fasting blood glucose (FBG), and standardized body mass index (BMI/SDS). Titration of basal and short-acting insulin doses was also evaluated.

RESULTS

Overall, 200 patients were identified. The mean age at the switch to Gla-300 was 13 years, and mean duration of diabetes was 3.9 years. Average HbA1c levels at switch were 8.8%. After 6 months, HbA1c levels decreased by - 0.88% (95% CI - 1.28; - 0.48; p < 0.0001). The benefit was maintained after 12 months from the switch (mean reduction of HbA1c levels - 0.80%, 95% CI - 1.25; - 0.35, p = 0.0006). Trends of reduction in FBG levels were also evidenced both at 6 months and 12 months. No significant changes in short-acting and basal insulin doses were documented.

CONCLUSIONS

The study provides the first real-world evidence of the effectiveness of Gla-300 in children and adolescents with T1D previously treated with 1BI. The benefits in terms of HbA1c levels reduction were substantial, and sustained after 12 months. Additional benefits can be expected by improving the titration of insulin doses.

Unmet needs in the treatment of type 1 diabetes: why is it so difficult to achieve an improvement in metabolic control?

The development of advanced diabetes technology has permitted persons with type 1 diabetes mellitus to improve metabolic control significantly, particularly with the development of advanced hybrid closed-loop systems which have improved the quality of life by reducing hypoglycemia, decreasing macroangiopathy and microangiopathy-related complications, ameliorating HbA1c and improving glycemic variability. Despite the progression made over the past few decades, there is still significant margin for improvement to be made in terms of attaining appropriate metabolic control. Various factors are responsible for poor glycemic control including inappropriate carbohydrate counting, repeated bouts of hypoglycemia, hypoglycemia unawareness, cutaneous manifestations due to localized insulin use and prolonged use of diabetes technology, psychosocial comorbidities such as eating disorders or 'diabulimia', the coexistence of insulin resistance among people with type 1 diabetes and the inability to mirror physiological endogenous pancreatic insulin secretion appropriately. Hence, the aim of this review is to highlight and overcome the barriers in attaining appropriate metabolic control among people with type 1 diabetes by driving research into adjunctive treatment for coexistent insulin resistance and developing new advanced diabetic technologies to preserve β cell function and mirror as much as possible endogenous pancreatic functions.

Perceptions Related to Death in Adolescents and Their Parents During the Management of Type 1 Diabetes: A Thematic Analysis

BACKGROUND

Type 1 diabetes (T1D) is associated with an increased risk of premature death compared to those without T1D, yet perceptions of dying have not been well studied. The purpose of this secondary analysis of existing data was to explore the fears of adolescents with T1D and their parents related to the possibility of death due to T1D.

METHOD

A reflexive thematic analysis was used to examine data from interviews conducted with adolescents with T1D and their parents who participated in a primary grounded theory study of interdependence in T1D management.

FINDINGS

Three themes were generated from the data including: (1) Facing the Reality of Death, (2) Fearing Highs and Lows, and (3) Finding a Way through Fears. Participants indicated they see death as a consequence of failing to optimally manage T1D.

CONCLUSION

Additional investigation is needed to explore the fear of death in adolescents with T1D and any fear their parents may have of their adolescents' mortality.

Recommendations for recognizing, risk stratifying, treating, and managing children and adolescents with hypoglycemia

There has been continuous progress in diabetes management over the last few decades, not least due to the widespread dissemination of continuous glucose monitoring (CGM) and automated insulin delivery systems. These technological advances have radically changed the daily lives of people living with diabetes, improving the quality of life of both children and their families. Despite this, hypoglycemia remains the primary side-effect of insulin therapy. Based on a systematic review of the available scientific evidence, this paper aims to provide evidence-based recommendations for recognizing, risk stratifying, treating, and managing patients with hypoglycemia. The objective of these recommendations is to unify the behavior of pediatric diabetologists with respect to the timely recognition and prevention of hypoglycemic episodes and the correct treatment of hypoglycemia, especially in patients using CGM or advanced hybrid closed-loop systems. All authors have long experience in the specialty and are members of the Italian Society of Pediatric Endocrinology and Diabetology. The goal of treating hypoglycemia is to raise blood glucose above 70 mg/dL (3.9 mmol/L) and to prevent further decreases. Oral glucose at a dose of 0.3 g/kg (0.1 g/kg for children using "smart pumps" or hybrid closed loop systems in automated mode) is the preferred treatment for the conscious individual with blood glucose <70 mg/dL (3.9 mmol/L), although any form of carbohydrate (e.g., sucrose, which consists of glucose and fructose, or honey, sugary soft drinks, or fruit juice) containing glucose may be used. Using automatic insulin delivery systems, the oral glucose dose can be decreased to 0.1 g/kg. Practical flow charts are included to aid clinical decision-making. Although representing the official position of the Italian Society of Pediatric Endocrinology and Diabetology (ISPED), these guidelines are applicable to the global audience and are especially pertinent in the era of CGM and other advanced technologies.

Insulin therapy in type 2 diabetes: Insights into clinical efficacy, patient-reported outcomes, and adherence challenges

Insulin therapy plays a crucial role in the management of type 2 diabetes as the disease progresses. Over the past century, insulin formulations have undergone significant modifications and bioengineering, resulting in a diverse range of available insulin products. These products show distinct pharmacokinetic and pharmacodynamic profiles. Consequently, various insulin regimens have em-erged for the management of type 2 diabetes, including premixed formulations and combinations of basal and bolus insulins. The utilization of different insulin regimens yields disparate clinical outcomes, adverse events, and, notably, patient-reported outcomes (PROs). PROs provide valuable insights from the patient's perspective, serving as a valuable mine of information for enhancing healthcare and informing clinical decisions. Adherence to insulin therapy, a critical patient-reported outcome, significantly affects clinical outcomes and is influenced by multiple factors. This review provides insights into the clinical effectiveness of various insulin preparations, PROs, and factors impacting insulin therapy adherence, with the aim of enhancing healthcare practices and informing clinical decisions for individuals with type 2 diabetes.

Educational outcomes and the role of comorbidity among adolescents with type 1-diabetes in Denmark

AIMS

To examine educational outcomes among adolescents with type 1 diabetes and determine the role of comorbidity.

METHODS

We conducted a nationwide register-based cohort study including 3370 individuals born between 1991 and 2003 and diagnosed with type 1 diabetes before the age of 16. They were all matched with up to four individuals without type 1 diabetes on age, gender, parents' educational level and immigration status. Information on comorbidity was based on hospital diagnoses. The individuals were followed in registers to determine whether they finished compulsory school (9th grade, usually at the age of 15-16 years), and were enrolled in secondary education by age 18 years.

RESULTS

Individuals with type 1 diabetes were more likely not to complete compulsory school (OR 1.44, 95% CI 1.26-1.64), and not being enrolled in an upper secondary education by age 18 (OR 1.50, 95% CI 1.31-1.73) compared to their peers. A total of 1869 (56%) individuals with type 1 diabetes were registered with at least one somatic (n = 1709) or psychiatric comorbidity (n = 389). Those with type 1 diabetes and psychiatric comorbidity were more likely not to complete compulsory school (OR 2.47, 95% CI 1.54-3.96), and not being enrolled in an upper secondary education by age 18 (OR 3.66, 95% CI 2.27-5.91) compared to those with type 1 diabetes only. Further, there was a tendency towards an association between having somatic comorbidity and adverse educational outcomes (OR 1.25, 95% CI 0.97-1.63; OR 1.26, 95% CI 0.95-1.66) among adolescents with type 1 diabetes. The associations differed markedly between diagnostic comorbidity groups.

CONCLUSION

Type 1 diabetes affects educational attainment and participation among adolescents. Psychiatric comorbidity contributes to adverse educational outcomes in this group, and there is a tendency that somatic comorbidity also plays a role.

Self-care activities in pediatric patients with type 1 diabetes mellitus

INTRODUCTION

Effective diabetes self-management and collaborative responsibility sharing with parents are imperative for pediatric patients with type 1 diabetes mellitus, particularly as they gradually assume more self-care responsibilities. The primary goal of this study was to assess differences in adherence to self-care activities regarding sociodemographics and clinical characteristics in pediatric patients with type 1 diabetes. The secondary goal of this study was to understand the level of parental involvement in diabetes management and to assess the pediatric patients' behaviors (independent or dependent on disease self-management) that relate to sociodemographic and clinical characteristics.

METHODS

This was a comparative cross-sectional and correlational study. The study sample included 182 children and adolescents who had been diagnosed with type 1 diabetes at least 3 months prior. Data collection instruments included a sociodemographic and questionnaire about Adherence to self-care activities and parental involvement in diabetes self-management, as well as a documentation sheet for recording clinical data.

RESULTS

A majority of participants (71%) exhibited non-adherence to self-care tasks, despite 78.0% asserting their independence in diabetes self-management. Notably, insufficient parental involvement in administering insulin therapy significantly predicted severe hypoglycemic episodes.

CONCLUSIONS

Pediatric patients dealing with type 1 diabetes demonstrate a substantial degree of autonomy in managing their condition, paradoxically coupled with self-reported non-adherence to critical self-care responsibilities. Notably, children (aged 8-12) rely more heavily on parental support, especially concerning insulin therapy administration. The study underscores the crucial role of parental engagement in insulin therapy, as its deficiency significantly predicts the likelihood of severe hypoglycemic episodes.

The Relationship Between Parent Fear of Hypoglycemia and Youth Glycemic Control Across the Recent-Onset Period in Families of Youth with Type 1 Diabetes

BACKGROUND

This study aims to examine the relationship between parents' fear of hypoglycemia (FH) over a 1-year period and child glucose metrics in 126 families of youth recently diagnosed with type 1 diabetes (T1D).

METHODS

Parents completed the Hypoglycemia Fear Survey for Parents (HFS-P) and uploaded 14 days of glucose data at a baseline, 6-month, and 12-month assessment.

RESULTS

Parents' HFS-P total and worry scores increased to a clinically meaningful degree from baseline to 6-month assessment, while multilevel models revealed within- and between-person variability in parents' HFS-P worry and behavior scores over time associated with child glycemia. Specifically, a significant negative relationship for within-person worry scores suggested that when parents reported higher than their average worry scores, their children recorded fewer glucose values in the target range, while within-person behavior scores suggested that when parents reported lower than their average behavior scores, their children recorded more values above the target range. There was also a negative relationship for between-person behavior scores with child glycated hemoglobin and a positive relationship for between-person behavior scores with child glucose values in the target range.

CONCLUSIONS

In the recent-onset period of T1D, parental FH worry and behavior associated with child glycemia possibly due to changes in parents' perceptions of their child's hypoglycemia risk. The clinically meaningful increases in parent FH in the recent-onset period and the negative association for between-person behavior scores with child glycated hemoglobin suggest that clinics should consider screening parents for FH, especially among parents of children with lower glycemic levels.

drCORRECT: An Algorithm for the Preventive Administration of Postprandial Corrective Insulin Boluses in Type 1 Diabetes Management

BACKGROUND

In type 1 diabetes therapy, precise tuning of postprandial corrective insulin boluses (CIBs) is crucial to mitigate hyperglycemia without inducing dangerous hypoglycemic events. Several heuristic formulas accounting for continuous glucose monitoring (CGM) trend have been proposed in the literature. However, these formulas suggest a lot of quantized CIB adjustments, and they lack personalization.

METHOD

drCORRECT algorithm proposed in this work employs a patient-specific time parameter and the "dynamic risk" (DR) measure to determine postprandial CIB suggestion. The expected benefits include the reduction of time in hyperglycemia, thanks to the preventive action exploited through DR. drCORRECT has been assessed retrospectively vs the literature methods proposed by Aleppo et al (AL), Bruttomesso et al (BR), and Ziegler et al (ZI) using a data set of 49 CGM daily traces recorded in free-living conditions. Retrospective evaluation of the algorithms is made possible by the use of ReplayBG, a digital twin-based tool that allows assessing alternative insulin therapies on already collected glucose data. Efficacy in terms of glucose control was measured by temporal, risk indicators, and dedicated hyperglycemic/hypoglycemic events metrics.

RESULTS

drCORRECT significantly reduces time spent in hyperglycemia when compared with AL and BR (33.52 [24.16, 39.89]% vs 39.76 [22.54, 48.15]% and 36.32 [26.91, 45.93]%, respectively); significantly reduces daily injected insulin (5.97 [3.80, 8.06] U vs 7.5 [5.21, 10.34] U), glycemia risk index (38.78 [26.58, 55.39] vs 40.78 [27.95, 70.30]), and time spent in hypoglycemia (0.00 [0.00, 1.74]% vs 0.00 [0.00, 10.23]%) when compared with ZI, resulting overall in a safer strategy.

CONCLUSIONS

The proposed drCORRECT algorithm allows preventive actions thanks to the personalized timing configuration and the introduction of the innovative DR-based CIB threshold, proving to be a valid alternative to the available heuristic literature methods.

How online peer support affects management efficacy and mitigates difficulties of parents caring for children with type 1 diabetes

The proper management of pediatric type 1 diabetes depends substantially on the parents of affected children. Parental psychological traits specifically related to diabetes caregiving influence the quality of their care and management of the disease in their children. Parents often use Facebook groups as sources of peer support and information about diabetes care. The present study aimed to examine the influence of devices used in diabetes management, ascertain the impact of Facebook peer-support groups on parental perceptions of problems and probe parental self-efficacy. 318 parents of children with type 1 diabetes completed an online questionnaire on demographics, diabetes-related data, and diabetes care-related psychological characteristics. Data analysis revealed three variables that determined competence in diabetes management: the utility of information and suggestions offered in the Facebook groups on diabetes; the form of insulin administration and membership in Facebook groups. Our results underpin that peer-support groups on social media platforms can serve as sources of the necessary information, support, and feedback on diabetes management competence for parents of children living with type 1 diabetes, they may thus facilitate parental diabetes management capabilities.

MiniMed 780G™ advanced hybrid closed-loop system performance in Egyptian patients with type 1 diabetes across different age groups: evidence from real-world users

BACKGROUND

Advanced hybrid closed loop (AHCL) system provides both automated basal rate and correction boluses to keep glycemic values in a target range.

OBJECTIVES

To evaluate the real-world performance of the MiniMed™ 780G system among different age groups of Egyptian patients with type 1diabetes.

METHODS

One-hundred seven AHCL system users aged from 3 to 71 years were enrolled. Data uploaded by patients were aggregated and analyzed. The mean glucose management indicator (GMI), percentage of time spent within glycemic ranges (TIR), time below range (TBR) and time above range (TAR) were determined.

RESULTS

Six months after initiating Auto Mode, patients spent a mean of 85.31 ± 22.04% of the time in Auto Mode (SmartGuard) and achieved a mean GMI of 6.95 ± 0.58% compared with 7.9 ± 2.1% before AHCL initiation (p < 0.001). TIR 70-180 mg/dL was increased post-AHCL initiation from 63.48 ± 10.14% to 81.54 ± 8.43% (p < 0.001) while TAR 180-250 mg/dL, TAR > 250 mg/dL, TBR < 70 mg/dL and TBR < 54 mg/dL were significantly decreased (p < 0.001). After initiating AHCL, TIR was greater in children and adults compared with adolescents (82.29 ± 7.22% and 83.86 ± 9.24% versus 78.4 ± 7.34%, respectively; p < 0.05). The total daily dose of insulin was increased in all age groups primarily due to increased system-initiated insulin delivery including auto correction boluses and basal insulin.

CONCLUSIONS

MiniMed™ 780G system users across different age groups achieved international consensus-recommended glycemic control with no serious adverse effects even in challenging age group as children and adolescents.

Hypoglycemia and Cardiovascular Disease: Exploring the Connections

It has long been known that administering insulin or insulin secretagogues to treat diabetes has the unfavorable side effect of hypoglycemia. Because hypoglycemia can disrupt normal brain function, it can have a profound impact on people's lives. Studies have shown a connection between hypoglycemia and a higher risk of death and cardiovascular disease. Through experimental studies, numerous potential reasons for the start of cardiovascular events have been discovered. In addition, studies on people have demonstrated that hypoglycemia can result in ventricular arrhythmias. According to recent studies, a number of factors may affect the relationship between hypoglycemia, cardiovascular events, and mortality. Confounding factors may explain the apparent correlation, at least in part. People with comorbidities may experience more hypoglycemia, increasing their risk of mortality. Those who have type 1 or type 2 diabetes, however, seem to be more susceptible to the negative effects of hypoglycemia on the cardiovascular system. When choosing appropriate glucose-lowering treatments and setting glycemic objectives with patients, clinicians should be aware of this risk.

The Advanced Hybrid Closed Loop Improves Glycemia Risk Index, Continuous Glucose Monitoring Index, and Time in Range in Children with Type 1 Diabetes: Real-World Data from a Single Center Study

Introduction: The Glycemia Risk Index (GRI) and Continuous Glucose Monitoring Index (COGI) are newly defined composite metric parameters derived from continuous glucose monitoring (CGM) data. GRI is divided into five separate risk zones (from lowest to highest: A-E). In this study, the effect of the advanced hybrid closed loop (AHCL) system on GRI and COGI in children with type 1 diabetes was evaluated. Materials and Methods: Forty-five children who had started using the AHCL and whose baseline and sixth-month CGM data were available were analyzed in terms of achievement of CGM consensus goals and changes in GRI scores and zones. The paired t-test was used for the analyses. Results: The mean age and duration of diabetes of the participants were 10.95 ± 3.41 and 3.85 ± 2.67 years, respectively. The mean GRI score significantly decreased from 35.66 ± 17.46 at baseline to 22.83 ± 9.08 at 6 months (P < 0.001). Although the proportion of those in the A zone was 20% at baseline, it increased to 42% at 6 months. AHCL also improved COGI from 72.59 ± 12.44 to 82.90 ± 7.72 (P < 0.001). Time in range (TIR) increased significantly from 70.54% to 80.51% (P < 0.001) at 6 months. Conclusion: AHCL provides not only an improvement in TIR but also a significant improvement in both GRI and COGI at 6 months. The incorporation of GRI and COGI alongside TIR may enhance the assessment of the glycemic profile by providing a more comprehensive and in-depth analysis.

Long-Term Benefits of an Integrated Continuous Glucose Monitoring and Insulin Pump System for Emergency Admissions, Hospitalization, and Metabolic Control in a Cohort of People With Diabetes: Retrospective Cohort Study

BACKGROUND

There is evidence in the literature that the use of sensor-augmented insulin pumps in patients with high-complexity diabetes improves metabolic control. However, there is no long-term information on clinical outcomes such as hospitalization or admission to the emergency room. This study describes outcomes for metabolic control, incidence of hospitalizations, and emergency room visits in a specific population using this technology.

OBJECTIVE

We aimed to assess long-term glycemic and clinical outcomes after the use of continuous subcutaneous insulin infusion and continuous glucose monitoring in people with diabetes.

METHODS

A retrospective cohort study was carried out in patients with diabetes previously treated with an intensive insulin regimen at a specialized diabetes treatment center who required a sensor-augmented insulin pump due to nonoptimal glycemic control. Glycated hemoglobin, severe hypoglycemic episodes, nonsevere hypoglycemic episodes, perception of hypoglycemia, and the incidence of emergency room visits and hospitalizations before and after treatment were evaluated.

RESULTS

Between January 2013 and August 2020, 74 patients with a median age of 36 (IQR 27-46) years were included in the study with a median 4 (IQR 2-7) years of follow-up. We found a statistically significant reduction in glycated hemoglobin (8.35% vs 7%; P<.001), nonsevere hypoglycemic episodes (71/74, 96% vs 62/74, 84%; P=.01), emergency room visits (42/73, 58% vs 4/62, 6%; P<.001), and hospitalizations (36/72, 50% vs 10/72, 14%; P<.001) after use of continuous subcutaneous insulin infusion.

CONCLUSIONS

The use of a sensor-augmented insulin pump associated with a strict follow-up program for patients with high-complexity diabetes led to a significant and sustained reduction in glycated hemoglobin and hypoglycemic episodes, as well as in the rate of emergency room visits and hospitalizations. These results encourage the adoption of this technology in patients who do not achieve metabolic control with optimal management of diabetes.

Assessing Parental Competence and Self-Ratings in Management of Pediatric Type 1 Diabetes and Emergency Glucagon Administration-An Exploratory Observational Study

BACKGROUND

Parents of pediatric patients with type I diabetes require competence in hypoglycemia management and skills in glucagon administration to deal with potentially life-threatening severe hypoglycemia. We aimed to compare parents' subjective self-ratings to an objective expert assessment of competences and skills in dealing with severe hypoglycemia.

METHODS

We interviewed 140 participants to assess their subjective self-ratings. The objective expert assessments used a standardized clinical case scenario of severe hypoglycemia and a practical demonstration of glucagon administration.

RESULTS

The participants self-rated their competence in hypoglycemia management as good (5) or very good (6), and their skills in administering glucagon as acceptable (3) [Scale: very poor (1) to very good (6)]. In the standardized clinical case scenario, 1.4% (2/140) of participants named all relevant steps of severe hypoglycemia management. In the practical demonstration of glucagon administration, 92.9% (130/140) of participants committed at least one drug handling error; 52.1% (73/140) committed at least one drug handling error rated with high clinical risk.

CONCLUSIONS

We found discrepancies regarding participants' subjective self-ratings compared to their performance in the respective objective expert assessments. These discrepancies indicate a lack of error awareness and the need for intervention studies to improve competence in hypoglycemia management and glucagon administration.

The impact of fear of hypoglycaemia on sleep in adolescents with type 1 diabetes

AIMS

Fear of hypoglycaemia (FOH) can contribute to impaired sleep for adults with type 1 diabetes (T1D) and parents of children with T1D, although it is unknown how FOH may affect sleep for adolescents with T1D. This study examines the relationship between adolescent FOH and sleep and assessed the influences of continuous glucose monitor (CGM) and insulin pump use.

METHODS

Adolescents ages 14-18 years with T1D completed questionnaires evaluating FOH (Child Hypoglycemia Fear Survey) and sleep (Pittsburgh Sleep Quality Index, PSQI). Analyses included linear and logistic regression, t-tests and Fisher's exact tests.

RESULTS

Participants included 95 adolescents (52 female) with a median (IQR) age of 16.5 (15.3-17.7) years and a T1D duration of 5.7 (2.5-9.6) years. Analyses showed increased FOH-Worry subscale scores were associated with reduced sleep duration (β = -0.03, p = 0.042, adjusting for BMI z-score, race and ethnicity) and increased sleep disturbances (OR = 1.1, p = 0.038, adjusting for race and ethnicity). Frequent CGM users had longer sleep duration (average 7.5 h) compared with infrequent or non-CGM users (average = 6.8 h; p = 0.029), and pump users had overall improved sleep health as determined by PSQI score (p = 0.019). Technology use did not have significant interactions in the relationships between FOH and sleep duration or sleep disturbances.

CONCLUSIONS

Worrying about hypoglycaemia was associated with impaired sleep for adolescents with T1D. Diabetes technology users have some sleep improvements, but CGM and pump use do little to alter the relationship between FOH and sleep outcomes.

Physical Activity Management for Youth With Type 1 Diabetes: Supporting Active and Inactive Children

Regular physical activity and exercise are important for youth and essential components of a healthy lifestyle. For youth with type 1 diabetes, regular physical activity can promote cardiovascular fitness, bone health, insulin sensitivity, and glucose management. However, the number of youth with type 1 diabetes who regularly meet minimum physical activity guidelines is low, and many encounter barriers to regular physical activity. Additionally, some health care professionals (HCPs) may be unsure how to approach the topic of exercise with youth and families in a busy clinic setting. This article provides an overview of current physical activity research in youth with type 1 diabetes, a basic description of exercise physiology in type 1 diabetes, and practical strategies for HCPs to conduct effective and individualized exercise consultations for youth with type 1 diabetes.

Is fear of hypoglycemia a major barrier to an active lifestyle in children and adolescents with type 1 diabetes? The Diactive-1 Study

Studies on fear of hypoglycemia as a barrier to physical activity among youth with type 1 diabetes (T1D) have been limited and controversial, most of which used self-reported assessment. The aim of the study was to evaluate the relationship between fear of hypoglycemia and physical activity and glycemic metrics in children and adolescents with T1D. Seventy-four participants (6-18 years of age; 44.6% females) with T1D were included in the study. Physical activity was assessed through accelerometry on nine consecutive days, and blood glucose metrics were simultaneously tracked using continuous glucose monitoring (time-in-range and hypoglycemic events). A closed question was used to evaluate the avoidance of physical activity due to fear of hypoglycemia. Fifteen participants (20%) reported avoiding physical activity due to fear of hypoglycemia. The group reporting no fear of hypoglycemia showed lower total physical activity (-35.33 min/day, 95% confidence interval [CI] (-77.57 to -1.47)) and light physical activity (-29.81 min/day, 95% CI -64.01 to -2.75) and higher sedentary time (77.95 min/day, 95% CI 26.46-136.87) per day compared with those with fear of hypoglycemia. No difference was found between those patients with fear of hypoglycemia in terms of meeting the recommendations of glycated hemoglobin, glucose coefficient of variation, and time-in-range when compared to those with no fear of hypoglycemia. In conclusion, children and adolescents with fear of hypoglycemia were more active, less sedentary, and had similar glycemic metrics to those without fear. Our results therefore suggest that fear of hypoglycemia may be less of a barrier to an active lifestyle than previously believed.

Daily diabetes-specific family conflict, problems, and blood glucose during adolescence

Diabetes-related family conflict is widely regarded as a risk factor for diabetes outcomes, yet it has not been examined on a daily basis. Parental acceptance may attenuate the degree to which family conflict is associated with diabetes outcomes. The present study examined (a) within- and between-person fluctuations in diabetes problems and family conflict, (b) within- and between-person links between conflict and blood glucose (BG) mean, and (c) whether parental acceptance moderated these associations. One hundred eighty adolescents (Mage = 12.92 years) with T1D completed a 14-day diary measuring diabetes problems, conflict with mother, conflict with father, and parental acceptance at the end of each day. Daily average BG values were calculated from glucometer readings. Higher diabetes problems on average across the 14-day diary were associated with more average conflict with mothers (between-person), but daily fluctuations in the number of diabetes problems were not related to daily conflict (within-person). Adolescents with higher conflict with mothers and fathers on average across the 14 days had higher BG means (between-person); however, on days when adolescents reported higher conflict, they had greater risk for low BG (within-person). Daily parental acceptance did not moderate associations between problems and conflict nor conflict and BG mean. This study was the first to examine daily diabetes-specific conflict with mothers and fathers during adolescence. The number of diabetes problems did not predict daily conflict. Fluctuations in daily conflict were associated with greater risk for low BG, underscoring the need for future research examining in-the-moment relations among conflict and BG extremes. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Implementation of Psychosocial Screening into Diabetes Clinics: Experience from the Type 1 Diabetes Exchange Quality Improvement Network

PURPOSE OF REVIEW

Although advances in diabetes technology and pharmacology have significantly and positively impacted diabetes management and health outcomes for some, diabetes care remains burdensome and can be challenging to balance with other life priorities. The purpose of this article is to review the rationale for assessment of psychosocial domains in diabetes care settings and strategies for the implementation of psychosocial screening into routine practice. Survey data from the Type 1 Diabetes Exchange Quality Improvement Network is highlighted.

RECENT FINDINGS

Implementation of psychosocial screening requires identifying the population; selecting validated tools to assess target domains; determining frequency of screening and mode of survey delivery; and scoring, interpreting, documenting, and facilitating referrals such that these processes are part of clinical workflows. Recognizing the influence of psychosocial factors for people with diabetes (PWD), professional society guidelines for comprehensive diabetes care recommend the integration of psychosocial screening into routine care.

Household Food Insecurity and Fear of Hypoglycemia in Adolescents and Young Adults With Diabetes and Parents of Youth With Diabetes

OBJECTIVE

To evaluate the relation between household food insecurity (HFI) and fear of hypoglycemia among young adults with type 1 and type 2 diabetes and adolescents with type 1 diabetes and their parents.

RESEARCH DESIGN AND METHODS

We analyzed cross-sectional data of 1,676 young adults with youth-onset diabetes (84% type 1, 16% type 2) and 568 adolescents (<18 years old; mean age 15.1 years) with type 1 diabetes from the SEARCH for Diabetes in Youth study. Adult participants and parents of adolescent participants completed the U.S. Household Food Security Survey Module. Adults, adolescents, and parents of adolescents completed the Hypoglycemia Fear Survey, where answers range from 1 to 4. The outcomes were mean score for fear of hypoglycemia and the behavior and worry subscale scores. Linear regression models identified associations between HFI and fear of hypoglycemia scores.

RESULTS

Adults with type 1 diabetes experiencing HFI had higher fear of hypoglycemia scores (0.22 units higher for behavior, 0.55 units for worry, 0.40 units for total; all P < 0.0001) than those without HFI. No differences by HFI status were found for adolescents with type 1 diabetes. Parents of adolescents reporting HFI had a 0.18 unit higher worry score than those not reporting HFI (P < 0.05). Adults with type 2 diabetes experiencing HFI had higher fear of hypoglycemia scores (0.19 units higher for behavior, 0.35 units for worry, 0.28 units for total; all P < 0.05) than those in food secure households.

CONCLUSIONS

Screening for HFI and fear of hypoglycemia among people with diabetes can help providers tailor diabetes education for those who have HFI and therefore fear hypoglycemia.

Improvement of Selected Psychological Parameters and Quality of Life of Patients With Type 1 Diabetes Mellitus Undergoing Transition From Multiple Daily Injections and Self-Monitoring of Blood Glucose Directly to the MiniMed 780G Advanced Hybrid Closed-Loop System: Post hoc Analysis of a Randomized Control Study

BACKGROUND

While introducing new technologies and methods of treatment for type 1 diabetes mellitus (T1DM), it seems essential to monitor whether modern technologies in diabetes treatment may improve the psychological and emotional status of patients.

OBJECTIVE

This study aims to assess the baseline psychological parameters of patients with T1DM during investigation of the direct transition from multiple daily injections (MDI) and self-monitoring of blood glucose (SMBG) to the MiniMed 780G advanced hybrid closed-loop (AHCL) system and to evaluate changes in the psychological well-being and quality of life (QoL) after the transition in these individuals versus the control group.

METHODS

The trial was a 2-center, randomized controlled, parallel group study. In total, 41 patients with T1DM managed with MDI or SMBG were enrolled and randomized either to the AHCL or the MDI+SMBG group. Of these, 37 (90%) participants (mean age 40.3 years, SD 8.0 years; mean duration of diabetes 17.3, SD 12.1 years; mean hemoglobin A_1c [HbA_1c] 7.2%, SD 1.0%) completed the study (AHCL: n=20, 54%; MDI+SMBG: n=17, 46%). Psychological parameters (level of stress, coping mechanisms, level of anxiety, self-efficacy level, acceptance of illness, locus of control of illness, life satisfaction, QoL) were measured at baseline and at the end of the study using 10 psychological questionnaires.

RESULTS

At baseline, the general level of stress of the examined patients was higher than in the general healthy Polish population (P=.001), but coping strategies used in stressful situations were significantly more effective and the level of self-efficacy (P<.001) was much higher than in the general population. The patients in this study accepted their illness more than patients with diabetes from the general Polish population (P<.001), but they felt that their health does not depend on them compared to the general population (P<.001). The overall life satisfaction was similar to that of the general population (P=.161). After 3 months from transition, the AHCL group reported an increase in 4 scales of the QoL-feeling well (P=.042), working (P=.012), eating as I would like (P=.011), and doing normal things (P=.034)-in comparison to the control group, where no significant change occurred. The level of both state anxiety and trait anxiety decreased in the AHCL group: State-Trait Anxiety Inventory (STAI) X1 scores (P=.009), STAI X1 stens (P=.013), and STAI X2 scores (P=.022). The AHCL group became more emotion oriented in stressful situations (Coping Inventory for Stressful Situations [CISS] E; P=.043) and significantly less self-blaming after 3 months of the study (P=.020).

CONCLUSIONS

The results indicate that the patients who decided to take part in the transition study were characterized by higher levels of stress than the general healthy population but had better coping strategies and self-efficacy. Furthermore, transitioning from MDI+SMBG treatment to the AHCL in patients naive to technology may significantly improve psychological well-being and QoL within 3 months. The rapidity of these changes suggests that they may be related to the significant improvement in glycemic outcomes but also significantly less burdened diabetes self-management.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04616391; https://clinicaltrials.gov/ct2/show/NCT04616391.

The Advanced Diabetes Technologies for Reduction of the Frequency of Hypoglycemia and Minimizing the Occurrence of Severe Hypoglycemia in Children and Adolescents with Type 1 Diabetes

Hypoglycemia is an often-observed acute complication in the management of children and adolescents with type 1 diabetes. It causes inappropriate glycemic outcomes and may impair the quality of life in the patients. Severe hypoglycemia with cognitive impairment, such as a convulsion and coma, is a lethal condition and is associated with later-onset cognitive impairment and brain-structural abnormalities, especially in young children. Therefore, reducing the frequency of hypoglycemia and minimizing the occurrence of severe hypoglycemia are critical issues in the management of children and adolescents with type 1 diabetes. Advanced diabetes technologies, including continuous glucose monitoring and sensor-augmented insulin pumps with low-glucose suspension systems, can reduce the frequency of hypoglycemia and the occurrence of severe hypoglycemia without aggravating glycemic control. The hybrid closed-loop system, an automated insulin delivery system, must be the most promising means to achieve appropriate glycemic control with preventing severe hypoglycemia. The use of these advanced diabetes technologies could improve glycemic outcomes and the quality of life in children and adolescents with type 1 diabetes.

Fear of hypoglycemia and associated factors in hospitalized patients with type 2 diabetes: a cross‑sectional study

The present cross-sectional survey was performed to assess the prevalence and factors associated with fear of hypoglycemia (FoH) in hospitalized patients with type 2 diabetes (T2D). Between July and December 2020, 494 patients with T2D were evaluated via structured questionnaires containing sociodemographic information, clinical information, and the Fear of Hypoglycemia-15 scale (FH-15). Patients were divided into the FoH and non-FoH groups according to the FH-15 score. Univariate and multivariate logistic regression analyses were performed to determine factors associated with FoH. Variables with P values < 0.1 in the univariate model were included in the multivariate model. In this study, the prevalence of FoH was 17.4% (86/494). 247 (50.0%) patients experienced hypoglycemic episodes in the past year, and 15 (3.0%) patients experienced severe hypoglycemic episodes in the past year. The mean age was 60.04 ± 11.71 years old, and female patients accounted for 39.9% of the sample. The item with the highest average FH-15 scores was: how often are you afraid of having hypoglycemia while alone? Multivariate logistic regression analysis indicated that living alone (OR 2.48; 95% CI 1.20-5.14; P = 0.015), number of hypoglycemic episodes in the past year (OR 1.06; 95% CI 1.03-1.10; P < 0.001), number of severe hypoglycemic episodes in the past year (OR 2.61; 95% CI 1.20-5.69; P = 0.016), and duration of insulin use (OR 1.06; 95% CI 1.02-1.10; P = 0.006) were associated with FoH. The prevalence of FoH in hospitalized patients with T2D was high. FoH was associated with living alone, number of hypoglycemic episodes in the past year, number of severe hypoglycemic episodes in the past year, and duration of insulin use. These findings can contribute to early decision-making for preventing, identifying, and improving FoH in patients with T2D. In the future, interventions aimed at reducing FoH to improve the harmful effects of FoH are necessary, such as increasing diabetes-related knowledge and skills, increasing social support, reducing psychological fear, and minimizing risks for hypoglycemic episodes.

Pharmacodynamics, pharmacokinetics, safety, and tolerability of a ready-to-use, room temperature, liquid stable glucagon administered via an autoinjector pen to youth with type 1 diabetes

BACKGROUND

Prompt and reliable management of hypoglycemia in youth with diabetes is important to prevent serious medical complications.

OBJECTIVES

To determine efficacy, pharmacodynamics (PD), pharmacokinetics (PK), safety, and tolerability of a ready-to-use, liquid stable glucagon formulation administered subcutaneously via an autoinjector pen to youth with type 1 diabetes (T1D).

METHODS

After plasma glucose concentration was < 80 mg/dL (< 4.4 mmol/L) after insulin, participants aged 2 to < 12 years with T1D were administered 0.5 mg of glucagon; participants aged 12 to < 18 years instead received 1 mg of glucagon. Then, adolescents were challenged with 0.5 mg after a 7- to 28-day washout period. Primary endpoint was mean plasma glucose concentration at 30 min after glucagon.

RESULTS

Plasma glucose concentrations significantly (p < 0.001) increased from baseline to 30 min after glucagon, with mean change in plasma glucose concentration between baseline and 30 min for each age cohort as follows: 2 to < 6 years (n = 7; 81.4 mg/dL [4.5 mmol/L]); 6 to < 12 years (13; 84.2 mg/dL [4.7 mmol/L]); 12 to < 18 years (11; dose, 1 mg; 54.0 mg/dL [3.0 mmol/L]); and 12 to < 18 years (11; 0.5 mg; 52.4 mg/dL [2.9 mmol/L]). Among age cohorts, no clinically relevant differences were observed for PD and PK parameters. Common adverse events were nausea, vomiting, and hypoglycemia.

CONCLUSION

Age-appropriate dosing of this glucagon formulation was effective at 30 min in reversing plasma glucose concentrations from < 80 mg/dL in youth with T1D.

Development and delivery of a brief family behavioral intervention to support continuous glucose monitor use in young children with type 1 diabetes

BACKGROUND

Despite potential glycemic benefits of continuous glucose monitor (CGM) use in young children with type 1 diabetes, psychosocial and behavioral challenges may interfere with sustained use. We developed a 5-session family behavioral intervention (FBI) to support CGM use.

OBJECTIVE

We report on the multi-step development of the FBI, training interventionists, implementation in a 14-site clinical trial, and participant satisfaction.

METHODS

A multidisciplinary team created the FBI based on mixed-methods (i.e., survey data, qualitative research) preliminary work with parents of young children. Investigators trained non-physician staff to deliver the 5 sessions per an intervention manual. Trial participants received the FBI either during the first (FBI group, n = 50) or second 6-months (Crossover group, n = 44) of the 1-year trial. Investigators listened to session recordings to rate intervention fidelity, and participants rated satisfaction with the FBI.

RESULTS

The complete 5-session FBI was delivered to 89% of participants, in-person (73%) or by telephone (23%). Sessions lasted 23 min on average, and fidelity was high across sessions. Over 80% of participants rated very high satisfaction with all aspects of the FBI and offered few recommendations for improvement.

CONCLUSIONS

Having been developed based on experiences and input of families of young children with type 1 diabetes, the FBI represented a novel behavioral approach to enhance sustained CGM use during a challenging developmental period. Evidence of strong feasibility and acceptability supports its potential for implementation in research and clinical care. As diabetes technologies evolve, the FBI may continue to be refined to address parents' most relevant concerns.

Related factors associated with fear of hypoglycemia in parents of children and adolescents with type 1 diabetes - A systematic review

PROBLEM

Fear of hypoglycemia is a significant concern for parents of children/ adolescents with type 1 diabetes. Although some studies have explained the parental fear of hypoglycemia, the related factors were yet to be determined. This systematic review aims to identify the related factors of fear of hypoglycemia in the parents of children and adolescents with type 1 diabetes and provide a theoretical basis for further intervention.

ELIGIBILITY CRITERIA

PubMed, MEDLINE, EMBASE, Scopus, CINAHL, EBSCO, Web of Science, and Cochrane Library were systematically searched from 2010 to 2021. Studies evaluating the fear of hypoglycemia of parents and its associated factors were included.

SAMPLE

Twenty-three observational articles met the criteria.

RESULTS

Significant associations were found between fear of hypoglycemia and specific factors, including motherhood, nocturnal hypoglycemia, and the number of blood glucose monitoring. Psychological factors, including anxiety, depression, pediatric parenting stress, mindfulness, self-efficacy, quality of life, and sleep disorders, were conclusive and associations with parental fear of hypoglycemia.

CONCLUSIONS

Understanding parental fear of hypoglycemia can help parents prevent potential problems in diabetes management, thus promoting children's growth. According to current evidence, effective targeted interventions based on modifiable relevant factors can be developed to reduce the fear of hypoglycemia in parents while maintaining optimal blood glucose control in children/ adolescents.

IMPLICATIONS

Health professionals should pay more attention to the mental health of parents, and parents should be involved in the care plan and have the opportunity to discuss their fear of hypoglycemia in the most appropriate way to manage type 1 diabetes.

Hybrid closed-loop therapy with a first-generation system increases confidence and independence in diabetes management in youth with type 1 diabetes

AIM

Hybrid closed-loop (HCL) therapy improves glycaemic control in adolescents with type 1 diabetes; however, little is known about their lived experience using these systems. The aim of this study was to explore the lived experiences of youth with type 1 diabetes using HCL therapy, and their parents, to provide insight into their lived experiences.

METHODS

Adolescents and young adults aged 12-25 years, who used Medtronic MiniMed™ 670G HCL system during a 6-month randomised clinical trial, and their parents, were invited to participate in a semi-structured interview at the end of the study. Open-ended questions were used to explore the lived experiences of families using HCL. The interviews were audio-recorded, transcribed and analysed using thematic analysis to determine the main themes.

RESULTS

In all, 17 young people with type 1 diabetes mean ± SD age: 17.5 ± 4.2 years, diabetes duration: 11.0 ± 4.9 years and HbA_1c 64 ± 9 mmol/mol (8.0 ± 0.8%) and 10 parents were interviewed. Three themes were identified: (1) 'Developing confidence and trust in the system', (2) 'Reduction in anxiety' and (3) 'Issues with device'. They reported a positive experience using HCL, with improvements in glucose levels and increased independence with diabetes management. However, frustration around the number of alarms and notifications associated with the system were also identified as issues.

CONCLUSION

Both youth and parents acknowledged the benefits of this first-generation HCL system in improving glycaemic outcomes and in providing flexibility and independence. These lived experiences provide valuable information in the introduction and provision of targeted education with HCL therapy.

Safety and Efficacy of Eucaloric Very Low-Carb Diet (EVLCD) in Type 1 Diabetes: A One-Year Real-Life Retrospective Experience

A eucaloric very low carbohydrate diet (EVLCD) is a diet with a daily caloric intake equal to the total daily energy expenditure (TDEE) with a carbohydrate content of <50 g/day. The literature on very low carbohydrate diets (VLCD) in type 1 diabetes (DM 1) is limited, although recently published scientific studies have highlighted their safety and efficacy in managing DM 1. In this retrospective analysis, we report the clinical data of 33 patients affected by DM 1 carrying out insulin therapy who switched voluntarily from their usual diet (high carb, low fat) to an EVLCD. Our aim is to evaluate the glycemic control, the amount of insulin needed in order to maintain glycemic control and safety of EVLCD. The switch improved glycemic control (mean glycated hemoglobin decreased from 8.3% to 6.8% (p < 0.01). The number of patients who reached a glycated hemoglobin value of <7% increased statistically from 12% to 57% (p < 0.01), and there was a statistically significant decrease (p < 0.01) in the units of daily insulin (from 36.7± 14.9 IU to 28.9 ±9.1 IU) A reduction from 54% to 24% in clinical level 2 hypoglycemia episodes was reported. No cases of severe hypoglycemia or ketoacidosis were observed. The results of the study support that EVLCD in DM 1 seems safe and effective when adopted under tight medical supervision.

Physical Activity, Glycemic Variability, and Parental Hypoglycemia Fear in Preschoolers With Type 1 Diabetes

PURPOSE

The authors examined associations between preschoolers' daily glycemic variability, parents' report of hypoglycemia fear, and preschoolers' daily moderate to vigorous physical activity (MVPA) and sedentary behavior (SB) in 25 families of preschoolers with type 1 diabetes.

METHODS

Parents completed a valid measure of hypoglycemia fear, and their child wore an accelerometer for up to 7 days. Parents provided glucose data from their child's devices. The authors used multiple regression and multilevel modeling to analyze their data.

RESULTS

Preschoolers (mean age 4.2 [1.7] y; 50% boys) engaged in a mean of 154.5 (59.6) and 339.2 (85.1) minutes of MVPA and SB per day, respectively, and parents reported relatively low levels of hypoglycemia worry and avoidance behaviors. Preschoolers' SB (r = .19, P = .02) and MVPA (r = -.20, P = .01) levels were significantly correlated with parental hypoglycemia worry scores but not with parents' hypoglycemia behavior scores (P = .15 and P = .92, respectively). While multilevel models did not show an association between MVPA and preschoolers' glycemic variability, preschoolers who engaged in more daily SB experienced higher glycemic variability (P = .04).

CONCLUSIONS

Research exploring MVPA, SB, and parental hypoglycemia fear in preschoolers with type 1 diabetes could have important clinical implications because it may reveal modifiable treatment targets that can impact preschoolers' health and activity patterns.

Bring Blood Glucose Down! An intervention to reduce fear of hypoglycemia in caregivers of adolescents with type 1 diabetes: Study design and participant characteristics

Fear of hypoglycemia (FOH) is anxiety or extreme worry about having a low blood glucose and its consequences. FOH is common in individuals with type 1 diabetes (T1D) of all ages, as well as their caregivers, and can lead to inappropriate T1D self-management and suboptimal health outcomes. Despite its prevalence and serious health consequences, there has been very little attention focused on developing interventions to reduce FOH and its associated maladaptive T1D management behaviors. The primary aim of the present study, Bring BG Down!, was to implement a pilot intervention targeting FOH in mothers of adolescents with T1D. Exploratory aims included determining if the intervention had an impact on the adolescent's FOH, glycemia, as well as other generalized anxiety symptoms or symptoms of obsessive-compulsive disorder in both the mother and adolescent. Caregiver participants and their adolescents with T1D were randomized to either the Bring BG Down! group or the Control group. Individuals in the Bring BG Down! group participated in intervention sessions for 6 months via telehealth and they completed questionnaires, whereas those in the Control group only completed questionnaires. Follow-up occurred at 7-months and 10-months. The purpose of this paper is to describe the Bring BG Down! study design and rationale, and participant characteristics at the start of the study.

The effect of do-it-yourself real-time continuous glucose monitoring on psychological and glycemic variables in children with type 1 diabetes: A randomized crossover trial

BACKGROUND

Continuous glucose monitoring (CGM) decreases fear of hypoglycemia (FOH) and improves glycemic control among those affected by type 1 diabetes (T1D). No studies to date have examined the impact of using do-it-yourself real-time continuous glucose monitoring (DIY RT-CGM) on psychological and glycemic outcomes.

METHODS

Child-parent dyads were recruited for a multicentre randomized crossover trial. Children with T1D were current intermittently scanned CGM (isCGM) users and aged 2-13 years. Families received either 6 weeks of DIY RT-CGM with parental remote monitoring (intervention) or 6 weeks of isCGM plus usual diabetes care (control), followed by a 4-week washout period, then crossed over. The primary outcome was parental FOH. Secondary outcomes were glycemic control using traditional CGM metrics, as well as a range of other psychosocial measures.

FINDINGS

Fifty five child-parent dyads were recruited. The child mean age was 9.1 ± 2.8 years. Although, there was no effect on parental FOH, -0.1 (95%CI: -0.3, 0.1, p = 0.4), time-in-range (TIR) (%3.9-10 mmol/L) was significantly higher with DIY RT-CGM over isCGM (54.3% ± 13.7 vs. 48.1% ± 13.6), mean difference, 5.7% (95%CI 1.8, 9.6, p <0.004). There was no difference for time spent in hypoglycemia. Parent diabetes treatment satisfaction was significantly higher following DIY RT-CGM compared to isCGM, mean difference 5.3 (95%CI: 2.3, 8.2, p <0.001).

CONCLUSION

The use of DIY RT-CGM versus isCGM did not improve parental FOH; however, TIR and parental satisfaction with diabetes treatment were significantly improved. This suggests in the short term, DIY RT-CGM appears safe and may offer families some clinically important advantages over isCGM.

Emergency Glucagon: a Focused Review of Psychosocial Experiences of Rescue Drugs for Type 1 Diabetes

PURPOSE OF REVIEW

The purpose of this paper is to describe rescue glucagon types, safety, efficacy, and preferences, as well as to review articles regarding emergency glucagon usage, severe hypoglycemia, and the emotions of both phenomena. We conducted a review of current literature on glucagon usage and the emotional impact of severe hypoglycemia on people with diabetes (PwD) and the caregivers of people with type 1 diabetes (T1D).

RECENT FINDINGS

Minimal research exists pertaining to glucagon and severe hypoglycemic experiences in PwD, which is troubling considering the severity of risks and possible side effects. Recent articles described negative emotions such as fear, anxiety, stress, helplessness, shame, embarrassment, loneliness, frustration, hopefulness, and uncertainty surrounding glucagon usage. There is scarce research regarding PwD's emotions surrounding severe hypoglycemia and rescue glucagon use. Additional research is needed to investigate the emotions and feelings people with T1D and their caregivers' experience pertaining to severe hypoglycemia and emergency glucagon use.

Experiences and needs of children with siblings diagnosed with Type 1 diabetes: A mixed studies systematic review

PROBLEM

The lives of family members for children with Type 1 diabetes mellitus (T1DM) after often shaped around the diagnosis as long-term/life-long care is needed. The combination of illness symptoms, treatment cost, and caregiving demands for T1DM negatively affects family functioning. While the experiences and needs of both parents and children suffering from T1DM are well documented, literature on healthy siblings of children with T1DM remains scarce.

PURPOSE

This systematic review aims to consolidate and examine the experiences and needs of siblings of children with T1DM.

ELIGIBILITY CRITERIA

Qualitative and quantitative studies exploring the experiences and needs of children under 18 years old whose siblings are diagnosed with T1DM.

SAMPLE

Six electronic databases (PubMed, CINAHL, PsycINFO, EMBASE, Scopus and ProQuest) were searched from inception till July 2021. Thirteen studies met the inclusion criteria and were subjected to narrative synthesis.

RESULTS

Four themes were generated from the synthesis: (1) emotional responses to sibling's condition, (2) stepping out of comfort zone, (3) changes in family dynamics, and (4) takeaways and a way forward.

CONCLUSIONS

The impact of T1DM diagnosis on siblings of children with T1DM suggest a need for healthcare providers to provide them better emotional and informational support, and allow them more involvement in the care for their sibling with T1DM.

IMPLICATIONS

Findings from this review will be able to inform policymakers on the development of future support programmes for children with T1DM and their families and encourage clinicians to revise T1DM care plans to be more family-centered. PROSPERO number: CRD42020204985.

Insulin Glargine 300 U/mL Therapy in Children and Adolescents with Type 1 Diabetes

The pharmacokinetic and pharmacodynamic properties of the second-generation basal insulin glargine 300 Units/mL (Gla-300) may be of benefit in the treatment of type 1 diabetes mellitus (T1DM). Gla-300 provides a stable and sustained time-action profile, which is associated with glycaemic control and flexible dosing schedule. This review summarises the available evidence on the safety and efficacy of Gla-300 in children and adolescents with T1DM. Gla-300 is as effective as the first-generation basal insulin glargine 100 Units/mL (Gla-100), a standard of care for patients with diabetes in reducing HbA1c, and shows a lower risk of severe hypoglycaemia and hyperglycaemia in children and adolescents with T1DM. However, Gla-300 and Gla-100 are not bioequivalent and are not directly interchangeable. Real-world studies on patients aged 6-17 years are limited. To date, only one small study assessed the effectiveness and safety of Gla-300 versus Gla-100 in newly diagnosed T1DM paediatric patients, confirming the treatment safety and effectiveness of Gla-300 in clinical practice. Gla-300 is a longer-acting basal insulin alternative in the management of children (aged ≥ 6 years) and adolescents with T1DM.

Effect of nationwide reimbursement of real-time continuous glucose monitoring on HbA1c, hypoglycemia and quality of life in a pediatric type 1 diabetes population: The RESCUE-pediatrics study

OBJECTIVE

Real-time continuous glucose monitoring (RT-CGM) can improve metabolic control and quality of life (QoL), but long-term real-world data in children with type 1 diabetes (T1D) are scarce. Over a period of 24 months, we assessed the impact of RT-CGM reimbursement on glycemic control and QoL in children/adolescents with T1D treated with insulin pumps.

RESEARCH DESIGN AND METHODS

We conducted a multicenter prospective observational study. Primary endpoint was the change in HbA1c. Secondary endpoints included change in time in hypoglycemia, QoL, hospitalizations for hypoglycemia and/or ketoacidosis and absenteeism (school for children, work for parents).

RESULTS

Between December 2014 and February 2019, 75 children/adolescents were followed for 12 (n = 62) and 24 months (n = 50). Baseline HbA1c was 7.2 ± 0.7% (55 ± 8mmol/mol) compared to 7.1 ± 0.8% (54 ± 9mmol/mol) at 24 months (p = 1.0). Participants with a baseline HbA1c ≥ 7.5% (n = 27, mean 8.0 ± 0.3%; 64 ± 3mmol/mol) showed an improvement at 4 months (7.6 ± 0.7%; 60 ± 8mmol/mol; p = 0.009) and at 8 months (7.5 ± 0.6%; 58 ± 7mmol/mol; p = 0.006), but not anymore thereafter (endpoint 24 months: 7.7 ± 0.9%; 61 ± 10mmol/mol; p = 0.2). Time in hypoglycemia did not change over time. QoL for parents and children remained stable. Need for assistance by ambulance due to hypoglycemia reduced from 8 to zero times per 100 patient-years (p = 0.02) and work absenteeism for parents decreased from 411 to 214 days per 100 patient-years (p = 0.03), after 24 months.

CONCLUSION

RT-CGM in pump-treated children/adolescents with T1D showed a temporary improvement in HbA1c in participants with a baseline HbA1c ≥ 7.5%, without increasing time in hypoglycemia. QoL was not affected. Importantly, RT-CGM reduced the need for assistance by ambulance due to hypoglycemia and reduced work absenteeism for parents after 24 months.

CLINICAL TRIAL REGISTRATION

[ClinicalTrials.gov], identifier [NCT02601729].

Parents' perceptions of quality of life of their children and adolescents with type 1 diabetes during Ramadan fasting in Riyadh

This study aimed to assess parents' perceptions of the quality of life (QoL) of their children with type 1 diabetes (T1D) during Ramadan fasting (RF). In this cross-sectional study, an Arabic-translated version of the standard diabetes-specific QoL questionnaire (PedsQL™ version 3.0) was used to compare perceptions of QoL during Ramadan month (Rm) versus non-Rm (NRm) of parents of children/adolescents with T1D from two tertiary hospitals in Riyadh. We used regression analysis to compare proxies (parents' reports) of their perceptions on their children/adolescents' QoL during Rm compared to NRm. A sample of 61 proxies (parents') of two age groups T1D offspring: 8-12 years (41%) and 13-18 years (59%) who reported their perceptions of their children/adolescents QoL during Rm were matched by children/adolescents' age and gender of 61 proxies in NRm. QoL scores of all domains were significantly lower in Rm compared to NRm; p < 0.0001, however, worries domain showed no statistical differences p = 0.052 in a regression analysis. The total aggregate median (IQR) in Rm was 850 (612-1,062) compared to 1,750 (1,475-2,062) in NRm, p < 0.001. The highest differences in NRm and Rm median scores were observed in communications (OR = 3.64; 95% CI 2.7-5.57) and treatment adherence (OR = 3.09; 95% CI 2.48-3.84) domains especially in the age of 13-18 years. Parents of adolescent boys, who are usually risk-takers and more exposed to outdoor activities, perceived lower QoL for them. Parents of adolescents with T1D perceived a lower QoL for their children during RF, especially in the treatment adherence and communication domains.

Conversations and Reactions Around Severe Hypoglycemia (CRASH) global survey of people with type-1 diabetes or insulin-treated type-2 diabetes and caregivers: findings from the French cohort

AIM

The objective of the CRASH (Conversations and Reactions Around Severe Hypoglycemia) survey was to further our understanding of the characteristics, experience, behavior and conversations with healthcare professionals (HCPs) of persons with diabetes (PWD) receiving insulin, and of their caregivers (CGs), concerning hypoglycemia requiring external assistance (severe hypoglycemic events [SHEs]).

METHODS

CRASH was an online cross-sectional survey conducted across eight countries. The PWDs with self-reported type 1 (T1D) or insulin-treated type 2 (T2D) diabetes were aged ≥18 years and had experienced one or more SHEs in past the 3 years; CGs were non-medical professionals aged ≥18 years, caring for a PWD meeting all the above criteria except for PWD age (≥4 rather than ≥18 years). The present report is a descriptive analysis of data from France.

RESULTS

Among PWDs who had ever discussed SHEs with an HCP, 38.9% of T1D PWDs and 50.0% of T2D PWDs reported that SHEs were discussed at every consultation; 26.3% and 8.8% respectively had not discussed the most recent SHE with an HCP. 35.7% of T1D PWDs and 53.8% of T2D PWDs reported that glucagon was not available to them at the time of their most recent SHE. Only 16.9% of T1D PWDs and 6.5% of T2D PWDs who had discussed their most recent SHE with an HCP reported that the HCP recommended obtaining a glucagon kit or asked them to confirm that they already had one. High proportions of PWDs and CGs reported that the most recent SHE had made them feel unprepared, scared and helpless and had affected mood, emotional state and activities.

CONCLUSION

CRASH survey data from France identify a need for greater discussion about SHEs between HCPs and PWDs and their CGs, and reveal gaps in the diabetes education of PWDs and CGs.

Clinically Serious Hypoglycemia Is Rare and Not Associated With Time-in-range in Youth With New-onset Type 1 Diabetes

CONTEXT

Early initiation of continuous glucose monitoring (CGM) is advocated for youth with type 1 diabetes (T1D). Data to guide CGM use on time-in-range (TIR), hypoglycemia, and the role of partial clinical remission (PCR) are limited.

OBJECTIVE

Our aims were to assess whether 1) an association between increased TIR and hypoglycemia exists, and 2) how time in hypoglycemia varies by PCR status.

METHODS

We analyzed 80 youth who were started on CGM shortly after T1D diagnosis and were followed for up to 1-year post diagnosis. TIR and hypoglycemia rates were determined by CGM data and retrospectively analyzed. PCR was defined as (visit glycated hemoglobin A1c) + (4*units/kg/day) less than 9.

RESULTS

Youth were started on CGM 8.0 (interquartile range, 6.0-13.0) days post diagnosis. Time spent at less than 70 mg/dL remained low despite changes in TIR (highest TIR 74.6 ± 16.7%, 2.4 ± 2.4% hypoglycemia at 1 month post diagnosis; lowest TIR 61.3 ± 20.3%, 2.1 ± 2.7% hypoglycemia at 12 months post diagnosis). No events of severe hypoglycemia occurred. Hypoglycemia was rare and there was minimal difference for PCR vs non-PCR youth (54-70 mg/dL: 1.8% vs 1.2%, P = .04; < 54mg/dL: 0.3% vs 0.3%, P = .55). Approximately 50% of the time spent in hypoglycemia was in the 65 to 70 mg/dL range.

CONCLUSION

As TIR gradually decreased over 12 months post diagnosis, hypoglycemia was limited with no episodes of severe hypoglycemia. Hypoglycemia rates did not vary in a clinically meaningful manner by PCR status. With CGM being started earlier, consideration needs to be given to modifying CGM hypoglycemia education, including alarm settings. These data support a trial in the year post diagnosis to determine alarm thresholds for youth who wear CGM.

Health-related quality of life in youth with type 1 diabetes: Associations with multiple comorbidities and mental health conditions

AIM

This cross-sectional study examined the associations of comorbid conditions on health-related quality of life (HRQOL) in 601 youth with type 1 diabetes. We evaluated associations between number of comorbid conditions (0, 1, ≥2) and particular comorbid conditions and youth HRQOL by self-report and parent proxy-report.

RESEARCH DESIGN AND METHODS

Youth with type 1 diabetes, aged 5-18 years, and their parents completed the PedsQL 4.0 Generic Core Scales self-report and parent proxy-report, respectively; they also reported youths' comorbid medical and mental health conditions. Separate linear regression models tested the relationship between number of comorbid conditions and specific comorbid conditions with youth-reported and parent proxy-reported HRQOL.

RESULTS

Youth with ≥2 comorbid conditions had significantly lower HRQOL by both self- and parent proxy-reports compared with youth with 0 or 1 comorbid condition (youth self-report: 0: 85 ± 12, 1: 85 ± 13, 2+: 78 ± 16, p = <0.0001; parent proxy-report: 0: 83 ± 12, 1: 81 ± 13, 2+: 74 ± 15, p = <0.0001). Amongst the comorbid conditions, only a mental health comorbidity was associated with lower HRQOL. For youth and parent proxy-reports, both the number of comorbidities (≥2) and the presence of a mental health comorbidity were significantly associated with lower HRQOL.

CONCLUSIONS

Health-related quality of life seems to be preserved in youth with type 1 diabetes unless confronted by multiple comorbidities as reported by youth and their parents. Our findings highlight the importance of tracking the presence of multiple comorbid conditions, possibly by reviewing problem and medication lists in the medical record, as well as screening for and addressing mental health conditions in routine diabetes care.

Psychosocial factors affecting the etiology and management of type 1 diabetes mellitus: A narrative review

Type 1 diabetes (T1D) is one of the most common chronic diseases in children and adolescents worldwide. Its etiopathogenesis results from the interplay of genetic and environmental variables. Among the latter, psychological stress has been implicated in disease onset as well as disease management. Various studies, including large population-based studies, have highlighted the role of stressful life events in the etiopathogenesis of T1D. In this article, we also emphasize the importance of attachment in the early child-caregiver relationship, which can be seen as a measure of the quality of the relationship and is crucial for stress and emotional regulation. It serves as a model for all subsequent relationships in one's life. We summarize some of the few studies performed in the field of attachment and T1D etiopathogenesis or management. T1D management demands a lifelong therapeutic regimen to prevent acute and chronic complications. In addition to psychological stress, psychological factors such as family functioning, developmental adjustment, autonomy, mental health problems and other factors have been found to relate to metabolic control. Psychological factors need to be understood not as a single directional causality-based principle but as a dynamic bi- or multidirectional system that is affected by the normal developmental transitions of childhood and adolescence.