Frequency and motives of blood glucose self-monitoring in type 1 diabetes

Personalizing the Use of a Intermittently Scanned Continuous Glucose Monitoring Device in Individuals With Type 1 Diabetes: A Cost-Effectiveness Perspective in the Netherlands (FLARE-NL 9)

AIMS

Intermittently scanned continuous glucose monitoring (isCGM) is a method to monitor glucose concentrations without using a finger prick. Among persons with type 1 diabetes (T1D), isCGM results in improved glycemic control, less disease burden and improved health-related quality of life (HRQoL). However, it is not clear for which subgroups of patients isCGM is cost-effective. We aimed to provide a real-world cost-effectiveness perspective.

METHODS

We used clinical data from a 1-year nationwide Dutch prospective observational study (N = 381) and linked these to insurance records. Health-related quality of life was assessed with the EQ-5D-3L questionnaire. Individuals were categorized into 4 subgroups: (1) frequent hypoglycemic events (58%), (2) HbA1c > 70 mmol/mol (8.5%) (19%), (3) occupation that requires avoiding finger pricks and/or hypoglycemia (5%), and (4) multiple indications (18%). Comparing costs and outcomes 12 months before and after isCGM initiation, incremental cost-effectiveness ratios (ICERs) were calculated for the total cohort and each subgroup from a societal perspective (including healthcare and productivity loss costs) at the willingness to pay of €50,000 per quality-adjusted life year (QALY) gained.

RESULTS

From a societal perspective, isCGM was dominant in all subgroups (ie higher HRQoL gain with lower costs) except for subgroup 1. From a healthcare payer perspective, the probabilities of isCGM being cost-effective were 16%, 9%, 30%, 98%, and 65% for the total cohort and subgroup 1, 2, 3, and 4, respectively. Most sensitivity analyses confirmed these findings.

CONCLUSIONS

Comparing subgroups of isCGM users allows to prioritize them based on cost-effectiveness. The most cost-effective subgroup was occupation-related indications, followed by multiple indications, high HbA1c and the frequent hypoglycemic events subgroups. However, controlled studies with larger sample size are needed to draw definitive conclusions.

Determinants of Self-monitoring of Blood Glucose in Iranian Children and Adolescents with Type 1 Diabetes

Background

Type 1 diabetes mellitus (T1DM) is a prevalent chronic disease among children and adolescents, necessitating effective self-monitoring of blood glucose (SMBG) levels. Understanding the determinants and factors influencing SMBG behavior is crucial for optimizing diabetes management in this population.

Objectives

This study aimed to investigate the frequency of SMBG and identify the determinants influencing factors in children and adolescents with T1DM.

Methods

This cross-sectional study was conducted in Tehran, Iran, and included 275 participants selected through simple random sampling from the Gabric Diabetes Education Association. The inclusion criteria comprised children and adolescents aged 3 - 18 years diagnosed with T1DM for at least 6 months who were using analog or neutral protamine Hagedorn (NPH) and regular insulin subcutaneously. Patients using insulin pumps were excluded. Data collection involved an online questionnaire covering demographic information (e.g., age, gender, educational status, and parental occupations) as well as clinical information (number of hypoglycemic episodes, hemoglobin A1C (HbA1C) levels, diabetes duration, insulin regimen, diabetes complications, glucose monitoring practices, hospitalizations, and behavioral characteristics). Statistical analyses, including descriptive statistics, correlation tests, and Poisson regressions, were performed using SPSS software (version 21). A significance level of P-value < 0.05 was considered statistically significant.

Results

The participants had a mean age of 10.00 ± 3.77 years, with 54.2% being males. Most of the participants (87.3%) were schoolchildren, and the mean age of diagnosis was 6.56 ± 3.73 years, with a mean duration of 44.72 ± 36.32 months. Anthropometric investigations revealed mean height, weight, and body mass index (BMI) values of 136.69 ± 21.11 cm, 37.45 ± 15.51 kg, and 18.31 ± 3.55 kg/m2, respectively. The majority of participants (93.5%) used insulin pens, and the mean daily insulin dosage was 35.34 ± 22.20 IU. Parents reported consistent glucose level monitoring in 64.7% of cases. The mean HbA1c level was 7.91 ± 1.58%. Factors such as the price and availability of glucometer strips influenced glucose level monitoring. In univariate analysis, only age and HbA1C levels showed a negative correlation; however, parents' consistent checking showed a positive correlation with the frequency of daily, weekly, or monthly glucose checking.

Conclusions

This study underscores the significance of SMBG in children and adolescents with T1DM. The findings emphasize the critical role of price and availability of glucometers and strips in achieving standard care for T1DM patients.

Validation and optimization of the French Generic Adherence for Chronic Diseases Profile (GACID-P) using classical test and item response theory

BACKGROUND

The Generic Adherence for Chronic Diseases Profile is a French generic scale (GACID-P) developed to measure adherence in several disease areas such as cardiology, rheumatology, diabetes, cancer and infectiology.

METHOD

We aimed to study the measurement invariance of the Generic Adherence for Chronic Diseases Profile by an item response model, optimize the new instrument version from item response model and qualitative content analyses results, and validate the instrument. The metric properties of the optimized version were studied according to classical test theory and item response model analysis.

RESULTS

A sample of 397 patients consulting at two French hospitals (in diabetes, cardiology, rheumatology, cancerology and infectiology) and in four private practices was recruited; 314 (79%) patients also completed the questionnaire 15 days later. Factor analyses revealed four dimensions: "Forgetting to take medication", "Intention to comply with treatment", "Limitation of risk-related consumer habits" and "Healthy lifestyle". The item response model and content analyses optimized these four dimensions, regrouping 32 items in four dimensions of 25 items, including one item conditioned on tobacco use. The psychometric properties and scale calibration were satisfactory. One score per dimension was calculated as the sum of the items for the dimensions "Forgetting to take medication" and "Intention to comply with treatment" and as a weighted score according to the item response model analysis for the two other dimensions because of differential item functioning found for two items.

CONCLUSION

Four adherence profile scores were obtained. The instrument validity was documented by a theoretical approach and content analysis. The Generic Adherence for Chronic Diseases Profile is now available for research targeting adherence in a broad perspective.

The Role of Exercise on Cardiometabolic Profile and Body Composition in Youth with Type 1 Diabetes

Exercise has a direct positive effect on glycemic control by promoting insulin secretion from β-pancreatic islet-cells and by increasing skeletal muscle glucose uptake. The reduction in daily insulin needs and the optimization of glycemic control improves the patient's quality of life, self-esteem, mental wellness, as well as diabetes-related mobility and mortality. The aim of this study was to investigate the effect of physical activity in children and adolescents with type-1 diabetes (T1D) on diabetic control, cardiovascular, and biochemical profiles; hs-CRP; IL6; leptin; and adiponectin levels of the population under study. This is a prospective cross-sectional study that involved 80 participants (36 boys and 44 girls) with T1D, who were aged 6-21 years and who attended the Diabetes and Metabolism Clinic of the 2nd Pediatric Department, University of Athens, "P & A Kyriakou" Children's Hospital of Athens. Twenty (25%) children were above the 75th percentile regarding total levels of physical activity, while 40 (50%) and 20 (25%) were between the 25th and 75th percentile, as well as below the 25th percentile, respectively. In the group with an intermediate level of exercise, physical activity was negatively associated with the participant's family situation (traditional, single parent, grandparent, with others, or by himself/herself) (p = 0.013), ferritin (p = 0.031), lipoprotein(a) [Lp(a)] (p = 0.016), and squared leptin levels (p = 0.040). Whereas in the groups with extreme vs. no exercise there was a negative association with the number of daily glucose measurements (p = 0.047). However, in the group with non-vigorous exercise, physical activity was positively associated with high density lipoprotein-c (HDL-c) levels (p = 0.048). The findings of this study are indicative of the beneficial role of exercise on children and adolescents with T1D, which is achieved by primarily improving their cardiometabolic profile through the amelioration of lipid profile [HDL-c, Lp(a)] and leptin levels, as well as by reducing chronic systemic inflammatory response (ferritin) and ultimately decreasing the overall diabetes morbidity.

Cost analysis of the flash monitoring system (FreeStyle Libre 2) in adults with type 1 diabetes mellitus

INTRODUCTION

Compare cost of the interstitial liquid glucose flash monitoring (FM) system (FreeStyle Libre 2) versus self-monitoring of blood glucose (SMBG) in adults with type 1 diabetes mellitus (T1DM) in Spain.

RESEARCH DESIGN AND METHODS

A model was developed to estimate, with the perspective of the Spanish health system, the annual costs associated with glucose monitoring and hypoglycemic events management in T1DM population, with multiple insulin daily doses (MDI). According to published evidence, rate of severe hypoglycemia (SHE) of 4.90 episodes per patient-year was applied. Reduction of SHE (58.6%) was modeled associated with FM use. Published rates of hospital care (20.2%) and subsequent admission (16%) were assumed for SHE. The daily consumption of strips and lancets was 9 in patients with SMBG (before and after 4 daily intakes and at bedtime) and 0.5 for FM users (according to IMPACT trial findings). Annual consumption of 26 FM sensors was considered (1 every 14 days). Unit costs (in € of 2019, excluding VAT) were obtained from literature and national databases. Sensitivity analyses (SA) were carried out to evaluate the model robustness.

RESULTS

The total annual cost/patient was €4437 for SMBG and €2526 for FM. The use of FM would be associated with an annual savings in the costs of monitoring and managing hypoglycemic events of €1911 per patient-year. In a hypothetical cohort of 1000 patients with T1DM MDI, FM could avoid in 1 year 4900 SHE, 93 hospitalizations for SHE. In addition, the use of FM would generate total savings of up to €1 910 000 per year. In the SA with alternative hypoglycemia events rates and use of strips and lancets, and including non-SHE episodes, savings from €370 000 to €1 760 000 were observed with FM.

CONCLUSIONS

The use of the FM system to monitor glucose in adults with T1DM treated with MDI, would reduce hypoglycemic events and would result in cost savings for the health system.

Decisions in the Psychology of Glucose Monitoring

This commentary aims to discuss the parallels between nonadherence to continuous glucose level monitoring and nonadherence to medication in people with diabetes and to investigate specific reasons for the difficulties involved in glucose monitoring. To this end, examples are given from both continuous and discontinuous glucose monitoring (CGM and SMBG, respectively).

The 3i Conceptual Framework for Recognizing Patient Perspectives of Type 1 Diabetes During Emerging Adulthood

IMPORTANCE

Early emerging adulthood, the developmental life stage roughly spanning between the ages of 18 and 24 years, can be a challenging time for individuals living with type 1 diabetes, being associated with an increased risk of acute complications, loss to follow-up, and the emergence of long-term diabetes complications. Few evidence-based interventions exist, and practice guidelines instead emphasize the importance of delivering individualized, developmentally appropriate care.

OBJECTIVE

To inform the provision of tailored care and education by illuminating the individual lived experiences of emerging adults with type 1 diabetes.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study used in-depth interviews conducted with 33 emerging adults living with type 1 diabetes between October 14, 2016, and May 16, 2017. Participants were recruited from 2 urban Young Adult Diabetes Clinics in the city of Toronto, Ontario, Canada, using a convenience sampling approach. Narrative analysis of participants' accounts was conducted inductively to define story typology.

MAIN OUTCOMES AND MEASURES

Participant accounts of type 1 diabetes during childhood, adolescence, and emerging adulthood.

RESULTS

Interviews were conducted with 33 participants aged 18 to 24 years (mean [SD] age at interview, 20.6 [1.7] years); 17 (51%) were women. Duration of diabetes ranged from 3 to 20 years (mean [SD] duration, 12.0 [4.8] years). Narrative analysis identified 3 distinct story types, or lenses, termed ingrained (n = 14), intrusive (n = 12), and inconspicuous (n = 7). Ingrained narratives portrayed an active integration of diabetes self-management into daily life. Intrusive narratives were characterized by stories of struggles for acceptance and striving for control. Inconspicuous narratives were differentiated by descriptions of a willingness to ignore diabetes and its attendant daily tasks with the goals of preserving normalcy and limiting distress. Mean levels of hemoglobin A1c were higher in participants conveying an intrusive lens narrative (mean [SD], 9.3% [1.6%]) than those conveying an ingrained lens (mean [SD], 7.4% [0.7%]) (difference between intrusive and ingrained, 1.9%; 95% CI, 0.8%-2.9%; P = .007) or an inconspicuous lens (mean [SD], 8.6% [1.5%]).

CONCLUSIONS AND RELEVANCE

Although every person is unique, there are commonalities in how emerging adults perceive and depict their experiences living with type 1 diabetes. Among the emerging adults interviewed in the present study, the 3i conceptual framework of ingrained, intrusive, and inconspicuous lenses encapsulated these commonalities. Recognition of the different psychosocial contexts surrounding type 1 diabetes during emerging adulthood may help health care professionals individualize their care accordingly.

Evaluation of a New Noninvasive Glucose Monitoring Device by Means of Standardized Meal Experiments

BACKGROUND

Frequent blood glucose readings are the most cumbersome aspect of diabetes treatment for many patients. The noninvasive TensorTip Combo Glucometer (CoG) component employs dedicated mathematical algorithms to analyze the collected signal and to predict tissue glucose at the fingertip. This study presents the performance of the CoG (the invasive and the noninvasive components) during a standardized meal experiment.

METHODS

Each of the 36 participants (18 females and males each, age: 49 ± 18 years, 14 healthy subjects, 6 type 1 and 16 type 2 patients) received a device for conducting calibration at home. Thereafter, they ingested a standardized meal. Blood glucose was assessed from capillary blood samples by means of the (non)invasive device, YSI Stat 2300 plus, Contour Next at time points -30, 0, 15, 30, 45, 60, 75, 90, 120, 150, and 180 minutes. Statistical analysis was performed by consensus error grid (CEG) and calculation of mean absolute relative difference (MARD) in comparison to YSI.

RESULTS

For the noninvasive (NI) CoG technology, 100% of the data pairs were found in CEG zones A (96.6%) and B (3.4%); 100% were seen in zone A for the invasive component and Contour Next. MARD was calculated to be 4.2% for Contour Next, 9.2% for the invasive component, and 14.4% for the NI component.

CONCLUSIONS

After appropriate individual calibration of the NI technology, both the NI and the invasive CoG components reliably tracked tissue and blood glucose values, respectively. This may enable patients with diabetes to monitor their glucose levels frequently, reliably, and most of all pain-free.

Role of Social Factors in Glycemic Control Among African American Children and Adolescents with Type 1 Diabetes

OBJECTIVE

With the rising incidence of Type 1 diabetes (T1DM), it is important to recognize deficiencies in care and areas of improvement to provide better access to resources and education for T1DM patients. The objective of this study was to recognize social factors and compliance barriers affecting glycated hemoglobin (A1c) level in T1D patients among the minority population.

METHODS

A total of 84 T1DM patients, ages 3 to 21 years, 49% males, 87% African American participated in the study. Study questionnaires assessing patient knowledge and other variables were distributed and patient charts were reviewed retrospectively to obtain relevant clinical data. T-tests, one-way ANOVA and spearman correlation were used for analysis.

RESULTS

Mean A1c in our study was 10.5% and mean knowledge score was 10.1 out of 14. There was no significant correlation (r = 0.12, p = 0.26) between A1c and patients' knowledge scores. Patients with more frequent blood sugar (BS) monitoring (3-4 times/day) had 2 points lower A1c (9.6 vs 11.6 %, 95% CI 0.2-3.7, p = 0.03) than those with 2 or less times/day. No significant difference in A1c between 3-4 checks/day vs >4 checks/day BS checks. Most patients reported 'forgetfulness' (19%) followed by 'too time consuming' (17.9%) as barriers to daily BS monitoring. There was no significant difference in A1c between pen or pump users (10.5 vs 10.2 %, p = 0.55). Surprisingly, those with home supervision had higher A1c than those without (10.7 vs 9.6 %, p = 0.04) while there was no significant difference between those with or without nurse supervision at school (10.6 vs 9.8 %, p = 0.33). Those reporting happy mood interestingly had higher A1c than those with sad/depressed mood (10.7 vs 9.4 %, p = 0.04). On multiple linear regression analysis, frequency of BS checks, home supervision and mood were the most significant predictors of A1c and altogether explained 20% of the variability in A1c.

CONCLUSION

Frequent BS monitoring is associated with lower A1c. Supervision at home and school did not improve A1c, but it was self-reported information. Mood did not affect A1c contrary to that reported in other studies.

Health Care Costs, Hospital Admissions, and Glycemic Control Using a Standalone, Real-Time, Continuous Glucose Monitoring System in Commercially Insured Patients With Type 1 Diabetes

BACKGROUND

Studies comparing standalone real-time continuous glucose monitoring (rtCGM) to self-monitoring of blood glucose (SMBG) in patients with type 1 diabetes mellitus (T1DM) have found that rtCGM is associated with lower glycated hemoglobin (A1C) levels, yet does not increase the risk of severe hypoglycemia. However, little is known about the relationship between rtCGM and health care costs and utilization. The objective of this study was to compare health care spending, hospital admissions, and A1C levels of patients using rtCGM to that of patients not using rtCGM.

METHODS

This retrospective, cross-sectional analysis used a large repository of health plan administrative data to compare average health care costs (excluding durable medical equipment), hospital admissions, and A1C levels of those using rtCGM (N = 1027) versus not using rtCGM (N = 32 583). To control for potentially confounding variables, a propensity score method was used to match patients using rtCGM to those not using rtCGM, based on characteristics such as age, gender, and comorbidities.

RESULTS

Patients using rtCGM spent an average of approximately $4200 less in total health care costs, when compared to patients not using rtCGM ( P < .05). They also experienced fewer hospital admissions ( P < .05) and lower A1C ( P < .05) during the postindex year.

CONCLUSIONS

Use of rtCGM by patients with T1DM is associated with lower health care costs, fewer hospital admissions, and better glycemic control.

Effect of switching from conventional continuous subcutaneous insulin infusion to sensor augmented pump therapy on glycemic profile in Japanese patients with type 1 diabetes

AIMS

Evidence suggests that sensor augmented pump (SAP) therapy is superior to conventional continuous subcutaneous insulin infusion (CSII) for achieving glycemic control in patients with type 1 diabetes. However, the clinical benefit of SAP therapy in East Asians has not yet been demonstrated.

METHODS

The effect of switching from conventional CSII to SAP therapy on glycemic profile was examined in 18 Japanese patients with type 1 diabetes. The glycemic profile of the patients was determined by retrospective continuous glucose monitoring (CGM) within 1 month before the treatment switch, whereas that at 6 and 12 months after the switch was evaluated with the CGM function of the SAP device. Hemoglobin A1c levels were also measured before and after the switch to SAP therapy.

RESULTS

The duration of hypoglycemia was significantly decreased at both 6 and 12 months after the change in treatment (6.6 ± 4.5, 3.2 ± 4.1, and 3.0 ± 2.8 min/h for before and 6 and 12 months, respectively), as was the HbA1c level at 12 months (7.8 ± 1.0 and 7.4 ± 0.9%, respectively). The duration of hyperglycemia did not differ between before and after the treatment switch. The decline in HbA1c level at 12 months after the switch to SAP was negatively correlated with age.

CONCLUSION

Switching from conventional CSII to SAP therapy was associated with a decrease in both the duration of hypoglycemia and the level of HbA1c in Japanese patients with type 1 diabetes.

A Randomized Clinical Trial of the Effect of Continuous Glucose Monitoring on Nocturnal Hypoglycemia, Daytime Hypoglycemia, Glycemic Variability, and Hypoglycemia Confidence in Persons with Type 1 Diabetes Treated with Multiple Daily Insulin Injections (GOLD-3)

BACKGROUND

To evaluate the effects of continuous glucose monitoring (CGM) on nocturnal and daytime hypoglycemia in persons with type 1 diabetes treated with multiple daily insulin injections (MDI); we also evaluated factors related to differences in hypoglycemia confidence in this population.

METHODS

Evaluations were performed from the GOLD randomized trial, an open-label multicenter crossover randomized clinical trial (n = 161) over 69 weeks comparing CGM to self-measurement of blood glucose (SMBG) in persons with type 1 diabetes treated with MDI. Masked CGM and the hypoglycemia confidence questionnaire were used for evaluations.

RESULTS

Time with nocturnal hypoglycemia, glucose levels <70 mg/dL was reduced by 48% (10.2 vs. 19.6 min each night, P < 0.001) and glucose levels <54 mg/dL by 65%. (3.1 vs. 8.9 min, P < 0.001). For the corresponding glucose cutoffs, daytime hypoglycemia was reduced by 40% (29 vs. 49 min, P < 0.001) and 54% (8 vs. 18 min., P < 0.001), respectively. Compared with SMBG, CGM use improved hypoglycemia-related confidence in social situations (P = 0.016) and confidence in more broadly avoiding serious problems due to hypoglycemia (P = 0.0020). Persons also reported greater confidence in detecting and responding to decreasing blood glucose levels (thereby avoiding hypoglycemia) during CGM use (P = 0.0033) and indicated greater conviction that they could more freely live their lives despite the risk of hypoglycemia (P = 0.022).

CONCLUSION

CGM reduced time in both nocturnal and daytime hypoglycemia in persons with type 1 diabetes treated with MDI and improved hypoglycemia-related confidence, especially in social situations, thus contributing to greater well-being and quality of life.

TRIAL REGISTRATION

ClinicalTrials.gov , number NCT02092051.

Factors associated with adherence to diabetes care recommendations among children and adolescents with type 1 diabetes: a facility-based study in two urban diabetes clinics in Uganda

PURPOSE

The purpose of this study was to determine the level of adherence and the factors associated with adherence to diabetes care recommendations among type 1 diabetic children and adolescents at two urban diabetes clinics in Kampala, Uganda.

RESEARCH DESIGN AND METHODS

A facility-based cross-sectional study was carried out among 200 children and adolescents with type 1 diabetes at two major diabetes clinics in Kampala. Caretakers of the children and adolescents were interviewed using pretested questionnaires to provide information on sociodemographic characteristics, diabetes care, knowledge, attitudes, and adherence to diabetes care recommendations in type 1 diabetes. Prevalence rate ratios (PRRs) at the 95% confidence interval (CI) were used to establish the factors associated with adherence using modified Poisson regression, with robust standard errors. The data were analyzed by using STATA Version 13.0.

RESULTS

The overall prevalence of adherence to diabetes care recommendations was at 37%. However, evaluating adherence to specific treatment parameters showed that 52%, 76.5%, and 29.5% of the children and adolescents adhered to insulin, blood glucose monitoring, and dietary recommendations, respectively. In the final adjusted model, active diet monitoring (adjusted PRR [APRR]: 1.95; 95% CI: 1.01, 3.78), being under care of a sibling (APRR: 1.66; 95% CI: 1.61, 1.71), being under care of a married caretaker (APRR: 1.10; 95% CI: 1.05, 1.14) and a separated or divorced caretaker (APRR: 1.60; 95% CI: 1.12, 2.27), taking three or less tests of blood glucose per day (APRR: 0.63; 95% CI: 0.42, 0.95), and having a caretaker with poor knowledge about diabetes (APRR: 0.49; 95% CI: 0.43, 0.57) and who is inactive in supervision of insulin injections (APRR: 0.58; 95% CI: 0.56, 0.60) were associated with adherence to type 1 diabetes care recommendations.

CONCLUSION

Adherence to type 1 diabetes care recommendations is still low among this population. The results suggest that reinforcing caretaker involvement could be vital in improving adherence to diabetes care recommendations in this population.

User Experience of an Innovative Mobile Health Program to Assist in Insulin Dose Adjustment: Outcomes of a Proof-Of-Concept Trial

BACKGROUND

Many patients with diabetes require insulin therapy to achieve optimal glycemic control. Initiation and titration of insulin often require an insulin dose adjustment (IDA) program, involving frequent exchange of blood glucose levels (BGLs) and insulin prescription advice between the patient and healthcare team. This process is time consuming with logistical barriers.

OBJECTIVE

To develop an innovative mobile health (m-Health) mobile-based IDA program (mIDA) and evaluate the user adherence and experience through a proof-of-concept trial.

METHODS

In the program, an m-Health system was designed to be integrated within a clinical IDA service, comprising a Bluetooth-enabled glucose meter, smartphone application, and clinician portal. Insulin-requiring patients with type-2 diabetes mellitus and stable BGL were recruited to use the m-Health system to record and exchange BGL entries, insulin dosages, and clinical messages for 2 weeks. The user experience was evaluated by a Likert scale questionnaire.

RESULTS

Nine participants, aged 58 ± 14 years (mean ± SD), completed the trial with average daily records of 3.1 BGL entries and 1.2 insulin dosage entries. The participants recognized the potential value of the clinical messages. They felt confident about managing their diabetes and were positive regarding ease of use and family support of the system, but disagreed that there were no technical issues. Finally, they were satisfied with the program and would continue to use it if possible.

CONCLUSIONS

The m-Health system for IDA showed promising levels of adherence, usability, perception of usefulness, and satisfaction. Further research is required to assess the feasibility and cost-effectiveness of using this system in outpatient settings.

Factors associated with greater benefit of a national reimbursement policy for blood glucose test strips in adult patients with type 1 diabetes: A prospective cohort study

AIMS/INTRODUCTION

We aimed to identify factors independently associated with greater benefit of a national reimbursement policy for blood glucose test strips in adult patients with type 1 diabetes, in terms of glycemic control and the rate of severe hypoglycemia.

MATERIALS AND METHODS

This was a prospective cohort study of 466 adult patients with type 1 diabetes from five tertiary referral hospitals who registered for a national reimbursement program for blood glucose strips and were then followed-up for 12 months. Factors associated with a > 5% reduction in glycated hemoglobin (HbA1c) and decreased rate of severe hypoglycemia (SH) at 12 months from baseline were evaluated.

RESULTS

At the end of the 12 months of follow up, 158 of 466 patients (33.9%) achieved >5% reduction in HbA1c, and 47 of 111 patients (42.3%) had a decreased rate of SH relative to baseline. Higher HbA1c (P < 0.001), lower total daily insulin dose at baseline (P = 0.048) and an increase in self-monitoring of blood glucose (SMBG) frequency during follow up (P = 0.001) were independently associated with >5% reduction in HbA1c. A higher SMBG frequency (P < 0.001), higher rate of SH at baseline (P = 0.029) and lack of hypoglycemic unawareness (P = 0.044) were independently associated with an increase in the frequency of SMBG during follow up. Higher SMBG frequency at baseline (P < 0.001) was independently associated with a decreased rate of SH.

CONCLUSIONS

Several factors, including higher SMBG frequency at baseline, were independently associated with reduced HbA1c and a decreased rate of severe hypoglycemia, showing that patients with these characteristics derive the most benefit from reimbursement of blood glucose test strips.

Using an Expert Panel to Develop Social Support Program Sequencing for Young Adults With Type 1 Diabetes

BACKGROUND

Young adults living with type 1 diabetes (T1DM) often encounter poor health outcomes, such as uncontrolled blood glucose levels. Social support programs can be a helpful method to support T1DM self-management. Effectively planning and tailoring social support programs for young adults living with T1DM are crucial for improving these programs and associated outcomes.

OBJECTIVES

This study convened an expert panel primarily composed of young adults living with T1DM to generate ideas and key components for sequential inclusion in social support programs prioritizing them.

METHOD

Exploratory expert panel meetings consisting of four individuals living with T1DM were held where Nominal Group Technique and Ideawriting exercises were used to develop themes and discussion points.

RESULTS

Six themes emerged from the meetings representing areas of difficulty for young adults living with T1DM. Topics such as following self-care recommendations, nutrition, handling stress, coping with social situations, and navigating the health care system were identified as important issues facing young adults.

CONCLUSIONS

By incorporating this approach into new or existing support group improved program discussions for young adults can be achieved and pertinent issues addressed, thus leading to improved health care outcomes.

Behavioral Analysis of Chinese Adult Patients with Type 1 Diabetes on Self-monitoring of Blood Glucose

BACKGROUND

The information-motivation-behavioral skills (IMB) model of health behavior is an effective tool to evaluate the behavior of diabetes self-management. The purpose of this study was to explore behavioral factors affecting the practice of self-monitoring of blood glucose (SMBG) within the frame of IMB model of health behavioral among adult patients with type 1 diabetes in a single diabetes clinic in China.

METHODS

A questionnaire with three subscales on SMBG information, motivation, and behavioral skills based on IMB model was developed. Validity and reliability of the measures were examined and guaranteed. Adult patients with type 1 diabetes visiting our diabetes clinic from January to March 2012 (n = 55) were consecutively interviewed. The self-completion questionnaires were administered and finished at face-to-face interviews among these patients. Both descriptive and correlational analyses were made.

RESULTS

Fifty-five patients finished the questionnaires, with the median duration of diabetes 4.5 years and the median of SMBG frequency 2.00. Specific SMBG information deficits, motivation obstacles, and behavioral skill limitations were identified in a substantial proportion of participants. Scores of SMBG motivation (r = 0.299, P= 0.026) and behavioral skills (r = 0.425, P= 0.001) were significantly correlated with SMBG frequency. The multiple correlation of SMBG information, SMBG motivation, and SMBG behavioral skills with SMBG frequency was R = 0.411 (R2 = 0.169, P= 0.023).

CONCLUSIONS

Adult patients with type 1 diabetes in our clinic had substantial SMBG information deficits, motivation obstacles, and skill limitations. This information provided potential-focused education targets for diabetes health-care providers.

Adherence of self-monitoring of blood glucose in persons with type 1 diabetes in Sweden

OBJECTIVE

The primary aim was to evaluate the extent to which persons with type 1 diabetes perform self-monitoring of blood glucose (SMBG) according to guidelines. Secondary objectives were to investigate predictors for good SMBG adherence, reasons for non-adherence, and association between SMBG frequency and hemoglobin A1c (HbA1c).

METHODS

This was a survey-based cross-sectional study. Questionnaires were sent out to 600 random patients at five sites. Patients were included if they were diagnosed with type 1 diabetes and ≥18 years old and excluded if they were currently using continuous glucose monitoring (CGM). Analysis of data was performed separately for the three sites where the answer frequency was ≥70%.

RESULTS

In total, 138 of 314 study participants, 43.9% (95% CI 38.5% to 49.4%) performed SMBG ≥4 times per day. For the three clinics where ≥70% of surveyed patients were included in the analysis, results were similar, 41.3% (95% CI 34.7% to 47.8%). Top three reported reasons for not performing more frequent SMBG were lack of time, not remembering, and self-consciousness. Frequency of SMBG was associated with HbA1c levels (p<0.0001). 30% of patients believed that ≤3 SMBG/day was recommended by healthcare providers.

CONCLUSIONS

Less than 50% of patients in Sweden follow guidelines of SMBG ≥4 times per day, despite glucose meters and strips being generally available at no cost. This indicates a need for further support in performing SMBG and increased availability of other tools for glucose monitoring.

Patterns of self-monitoring of blood glucose in insulin-treated diabetes: analysis of a Scottish population over time

Analysis of a diabetes clinical information system in Tayside, Scotland, shows that a significant proportion of insulin-treated patients with diabetes are not self-monitoring blood glucose according to current clinical guidance and recommendations, with some not self-monitoring their blood glucose at all. Although there has been an increase in the number of reagent strips dispensed over the past decade, this increase is mainly accounted for by increased testing frequency among people with diabetes already testing.

Design and Methods of a Randomized Trial of Continuous Glucose Monitoring in Persons With Type 1 Diabetes With Impaired Glycemic Control Treated With Multiple Daily Insulin Injections (GOLD Study)

BACKGROUND

The majority of individuals with type 1 diabetes today have glucose levels exceeding guidelines. The primary aim of this study was to evaluate whether continuous glucose monitoring (CGM), using the Dexcom G4 stand-alone system, improves glycemic control in adults with type 1 diabetes treated with multiple daily insulin injections (MDI).

METHODS

Individuals with type 1 diabetes and inadequate glycemic control (HbA1c ≥ 7.5% = 58 mmol/mol) treated with MDI were randomized in a cross-over design to the Dexcom G4 versus conventional care for 6 months followed by a 4-month wash-out period. Masked CGM was performed before randomization, during conventional treatment, and during the wash-out period to evaluate effects on hypoglycemia, hyperglycemia, and glycemic variability. Questionnaires were used to evaluate diabetes treatment satisfaction, fear of hypoglycemia, hypoglycemia confidence, diabetes-related distress, overall well-being, and physical activity during the different phases of the trial. The primary endpoint was the difference in HbA1c at the end of each treatment phase.

RESULTS

A total of 205 patients were screened, of whom 161 were randomized between February and December 2014. Study completion is anticipated in April 2016.

CONCLUSIONS

It is expected that the results of this study will establish whether using the Dexcom G4 stand-alone system in individuals with type 1 diabetes treated with MDI improves glycemic control, reduces hypoglycemia, and influences quality-of-life indicators and glycemic variability.

The use of engineered protein materials in electrochemical devices

Bioelectrochemical technologies have an important and growing role in healthcare, with applications in sensing and diagnostics, as well as the potential to be used as implantable power sources and be integrated with automated drug delivery systems. Challenges associated with enzyme-based electrodes include low current density and short functional lifetimes. Protein engineering is emerging as a powerful tool to overcome these issues. By taking advantage of the ability to precisely define protein sequences, electrodes can be organized into high performing structures, and enable the next generation of medical devices.

Remote Health Consultations Supported by a Diabetes Management Web Application With a New Glucose Meter Demonstrates Improved Glycemic Control

BACKGROUND

Cloud-connected diabetes applications enable health care professionals (HCPs) to monitor patient progress and offer the potential for remote consultations. OneTouch Reveal (OTR) is a cloud-based web application that aggregates data from blood glucose (BG) meters or insulin pumps and provides analytics to help patients and HCPs make more informed treatment and lifestyle decisions. This study assessed the experience of patients using OTR and the OneTouch Verio (OTV) BG meter and determined the extent of changes in glycemic control.

METHODS

Subjects with T1DM (23) or T2DM (17) uploaded BG meter results to OTR for 12 weeks. HCPs remotely reviewed progress using OTR and delivered telephone consultations at 4 and 8 weeks based on OTR insights.

RESULTS

After 12 weeks, mean HbA1c decreased by 0.4% (P < .001) and 25% of subjects had a reduction of ≥1.0%. Reduction in HbA1c was similar in subjects with T1DM and T2DM, although subjects with T1DM started with higher baselines. In subjects with T2DM, mean BG decreased significantly from 175 to 161 mg/dl (P < .001) with the percentage of above-range BG results decreasing from 33% to 24%. 80% of subjects confirmed OTR detected out-of-range glucose patterns and 84% of these subjects were able to correct the underlying pattern to get BG back in-range.

CONCLUSIONS

OTR web application in combination with the OTV meter helped subjects with T1DM and T2DM effectively manage their diabetes and was associated with improved BG control over 12 weeks. Real-time visibility to subject data may help HCPs deliver focused and effective remote consultations.

Influences on Technology Use and Efficacy in Type 1 Diabetes

The majority of people with type 1 diabetes have suboptimal glycemic control, increasing their complication risk. Technology to support diabetes self-care has advanced significantly and includes self-monitoring of blood glucose (SMBG), insulin pump therapy (IPT), continuous glucose monitoring (CGM), and sensor-augmented pump therapy (SAPT), which are stepping stones toward the "artificial pancreas" using closed-loop technology. Use of these technologies improves clinical outcomes for patients with the appropriate skills and motivation. This review addresses the psychosocial factors that influence both technology provision and clinical outcome and also how technology impacts on psychological outcomes. Optimal use of the various diabetes self-management technologies is influenced by previous self-care behaviors, demographic and psychological factors. Provision of IPT is also influenced by the same factors. Despite technology increasing the complexity of treatment, the lack of evidence for adverse psychological outcomes is reassuring. Treatment satisfaction is high, and discontinuation rates are low. However, technology will widen the health inequality gap if its use is limited to motivated patients who demonstrate good self-care behaviors. Pivotal to the success of the various technologies is provision of appropriate education at initiation of the technology, regular ongoing contact for treatment adjustments and trouble-shooting device issues plus access to psychological support when required. Additional support strategies may be required to help patients struggling with their diabetes to benefit from the available technology, recognizing that they may have most to gain.

Physical activity and type 1 diabetes: time for a rewire?

While being physically active bestows many health benefits on individuals with type 1 diabetes, their overall blood glucose control is not enhanced without an effective balance of insulin dosing and food intake to maintain euglycemia before, during, and after exercise of all types. At present, a number of technological advances are already available to insulin users who desire to be physically active with optimal blood glucose control, although a number of limitations to those devices remain. In addition to continued improvements to existing technologies and introduction of new ones, finding ways to integrate all of the available data to optimize blood glucose control and performance during and following exercise will likely involve development of "smart" calculators, enhanced closed-loop systems that are able to use additional inputs and learn, and social aspects that allow devices to meet the needs of the users.

Improving Self-Monitoring of Blood Glucose among Adults with Type 1 Diabetes: Results of the Mobile™ Study

INTRODUCTION

The objective of this study was to determine whether people with type 1 diabetes are more likely to self-monitor their blood glucose (SMBG) as recommended by their diabetes health care professional using the Accu-Chek Mobile™ (F. Hoffmann-La Roche AG, Basel, Switzerland) monitoring system compared to the Freestyle Optium™ (Abbott, North Chicago, IL, USA).

METHODS

Thirty-five participants with type 1 diabetes participating in a randomized cross-over study were assigned to monitor their blood glucose levels for a 3-month period using the Accu-Chek Mobile or the Freestyle Optium monitoring system and then to cross-over to the alternative device. After completion of the 6-month cross-over period, participants were invited to select their meter of choice and were followed for a further 3 months.

RESULTS

SMBG frequency increased in both groups but participants monitored significantly more often using the Accu-Chek Mobile meter (frequency SMBG/week median: 19 vs. 10, P = 0.04). After 3 months using each meter, 77% of participants indicated a preference for the Accu-Chek Mobile meter. Monitoring frequency in this group remained higher than baseline during the 3-month post-cross-over follow-up period.

CONCLUSION

Our results indicate that the Accu-Chek Mobile meter improves SMBG frequency. After experience of both systems, Accu-Chek Mobile was the meter of choice for the majority of participants in this study.

FUNDING

Roche Diabetes Care Unconditional Education Grant.

The psychosocial and financial impact of non-severe hypoglycemic events on people with diabetes: two international surveys

OBJECTIVES

To understand the impact of nocturnal and daytime non-severe hypoglycemic events on healthcare systems, work productivity and quality of life in people with type 1 or type 2 diabetes.

METHODS

People with diabetes who experienced a non-severe hypoglycemic event in the 4 weeks prior to the survey were eligible to participate in a nocturnal and/or daytime hypoglycemia survey. Surveys were conducted in Argentina, Australia, Brazil, Israel, Mexico and South Africa.

RESULTS

In total, 300 respondents were included in nocturnal/daytime hypoglycemia surveys (50/participating country/survey). All respondents with type 1 diabetes and 68%/62% (nocturnal/daytime) with type 2 diabetes were on insulin treatment. After an event, 25%/30% (nocturnal/daytime) of respondents decreased their insulin dose and 39%/36% (nocturnal/daytime) contacted a healthcare professional. In the week after an event, respondents performed an average of 5.6/6.4 (nocturnal/daytime) additional blood glucose tests. Almost half of the respondents (44%) reported that the event had a high impact on the quality of their sleep. Among nocturnal survey respondents working for pay, 29% went to work late, 16% left work early and 12% reported missing one or more full work days due to the surveyed event. In addition, 50%/39% (nocturnal/daytime) indicated that the event had a high impact on their fear of future hypoglycemia.

CONCLUSIONS

The findings suggest that nocturnal and daytime non-severe hypoglycemic events have a large financial and psychosocial impact. Diabetes management that minimizes hypoglycemia while maintaining good glycemic control may positively impact upon the psychological wellbeing of people with diabetes, as well as reducing healthcare costs and increasing work productivity.

Polymers in cell encapsulation from an enveloped cell perspective

In the past two decades, many polymers have been proposed for producing immunoprotective capsules. Examples include the natural polymers alginate, agarose, chitosan, cellulose, collagen, and xanthan and synthetic polymers poly(ethylene glycol), polyvinyl alcohol, polyurethane, poly(ether-sulfone), polypropylene, sodium polystyrene sulfate, and polyacrylate poly(acrylonitrile-sodium methallylsulfonate). The biocompatibility of these polymers is discussed in terms of tissue responses in both the host and matrix to accommodate the functional survival of the cells. Cells should grow and function in the polymer network as adequately as in their natural environment. This is critical when therapeutic cells from scarce cadaveric donors are considered, such as pancreatic islets. Additionally, the cell mass in capsules is discussed from the perspective of emerging new insights into the release of so-called danger-associated molecular pattern molecules by clumps of necrotic therapeutic cells. We conclude that despite two decades of intensive research, drawing conclusions about which polymer is most adequate for clinical application is still difficult. This is because of the lack of documentation on critical information, such as the composition of the polymer, the presence or absence of confounding factors that induce immune responses, toxicity to enveloped cells, and the permeability of the polymer network. Only alginate has been studied extensively and currently qualifies for application. This review also discusses critical issues that are not directly related to polymers and are not discussed in the other reviews in this issue, such as the functional performance of encapsulated cells in vivo. Physiological endocrine responses may indeed not be expected because of the many barriers that the metabolites encounter when traveling from the blood stream to the enveloped cells and back to circulation. However, despite these diffusion barriers, many studies have shown optimal regulation, allowing us to conclude that encapsulated grafts do not always follow nature's course but are still a possible solution for many endocrine disorders for which the minute-to-minute regulation of metabolites is mandatory.

A cross-sectional study of glycaemic control, complications and psychosocial functioning among 18- to 35-year-old adults with type 1 diabetes

AIMS

To describe the level of glycaemic control, complications and psychosocial functioning and the relationships between these variables in the under-researched group of younger adults with type 1 diabetes.

METHODS

Local electronic health records provided data on age, gender, disease duration, HbA1c and complications for 710 younger adults (18-35 years) with type 1 diabetes. A questionnaire with wide-ranging psychometric scales was used to measure various aspects of psychosocial functioning: the burden of diabetes-related problems, well-being, self-esteem, perceived competence in managing diabetes, perceived autonomy support from health professionals and self-management motivations. Furthermore, patients reported weekly self-monitored blood glucose measurements and insulin administration. Associations between HbA1c , complication and psychosocial indicators were tested using linear and logistic regression models, adjusted stepwise for confounders, including age, gender, diabetes duration, continuous subcutaneous insulin infusion, smoking and BMI.

RESULTS

In total, 406 (57%) participants responded. The responders had a mean age of 27.1 (5.1) years, a mean diabetes duration of 13.5 (7.9) years and an HbA1c of 66 mmol/mol (8.2%), with similar values for both genders (P = 0.87). Complications were observed among women more commonly than among men (31.6 vs. 18.8%, P < 0.01), and high distress levels were more prevalent among women compared with men (51.2 vs. 31.9%, P < 0.0001). Except for perceived autonomy support, the psychosocial variables were all associated with HbA1c (P < 0.001).

CONCLUSIONS

The high prevalence of poor glycaemic control, early complications and psychosocial distress require health-promoting interventions tailored to the interrelated clinical and psychosocial needs of younger adults with type 1 diabetes.

Blood glucose pattern management in diabetes: creating order from disorder

BACKGROUND

Self-monitoring of blood glucose (SMBG) is the most accessible way to assess glycemic patterns, and interpretation of these patterns can provide reasons for poor glycemic control and suggest management strategies. Furthermore, diabetes management based on blood glucose (BG) patterns is associated with improved patient outcomes. The aim of this review is therefore to evaluate the impact of pattern management in clinical practice.

METHODS

We included a review of available literature, a discussion of obstacles to implementation of SMBG and pattern management, and suggestions on how clinicians and patients might work together to optimize this management feature.

RESULTS

The literature review revealed eight publications specifically describing structured approaches to SMBG and pattern management. Specific information on how SMBG might be structured to detect BG patterns, however, remains limited. Barriers to pattern management include not just practical reasons, but emotional and psychological reasons as well.

CONCLUSIONS

Patterns are not always easy to detect or interpret, but on-meter and web-based tools can support both patients and clinicians. Ultimately, successful pattern management requires education and mutual commitment from the clinician and patient--ongoing collaboration is needed to obtain, review, and interpret SMBG values and to make changes based on the patterns.

Determinants of self-monitoring of blood glucose in patients with Type 1 diabetes: a multi-centre study in Brazil

AIM

The aim of this study was to determine the relationship between the daily frequency of self-monitoring of blood glucose and glycaemic control, demographic and socio-economic status in patients with Type 1 diabetes under routine clinical care in Brazil.

METHODS

This was a cross-sectional, multi-centre study conducted between December 2008 and December 2010 in 28 public clinics in 20 Brazilian cities. The data were obtained from 3176 patients, aged 22 ± 11.8 years, of whom 56.3% were female and 57.4% were Caucasian. The mean time since diabetes diagnosis was 11.7 ± 8.1 years.

RESULTS

The prevalence of self-monitoring of blood glucose was 88.5%. There was a significant increase in self-monitoring frequency associated with female gender, lower ages, more intensive diabetes management and higher socio-economic status. A correlation between HbA(1c) levels and the daily frequency of self-monitoring was observed (r(s) = -0.13; P = 0.001). The mean HbA1c levels were related to the daily frequency of self-monitoring (P < 0.001) without additional benefit to patients who performed self-monitoring more than four times daily (9.2, 11.2, 10.2,15.2 and 15% for one, two, three, four, five or more self-monitoring tests daily, respectively; P < 0.0001).

CONCLUSIONS

The majority of our patients (88.5%) performed three or more self-monitoring tests daily, with more frequent testing reported by females, younger patients, those on intensive insulin regimens and of higher socio-economic status. No additional benefit was found in patients who performed self-monitoring more than four times daily. The diabetes care team must improve patients' education regarding self-monitoring of blood glucose and its benefits.

Integrated self-monitoring of blood glucose system: handling step analysis

Self-monitoring of blood glucose (SMBG) implicates a number of handling steps with the meter and the lancing device. Numerous user errors can occur during SMBG, and each step adds to the complexity of use. This report compares the required steps to perform SMBG of one fully integrated (the second generation of the Accu-Chek® Mobile), three partly integrated (Accu-Chek Compact Plus, Ascensia® Breeze®2, and Accu-Chek Aviva), and six conventional (Bayer Contour®, Bayer Contour USB, BGStar™, FreeStyle Lite®, OneTouch® Ultra® 2, and OneTouch Verio™Pro) systems. The results show that the fully integrated system reduces the number of steps to perform SMBG. The mean decrease is approximately 70% compared with the other systems. We assume that a reduction of handling steps also reduces the risk of potential user errors and improves the user-friendliness of the system.

Noninvasive monitoring of glucose levels: is exhaled breath the answer?

Monitoring of blood glucose levels is clinically important in the management of diseases affecting insulin secretion and resistance, most notably diabetes mellitus and cystic fibrosis. Typically, blood glucose monitoring is an invasive technique that may cause distress and discomfort, particularly in the pediatric population. Development of noninvasive methods of monitoring blood glucose is therefore indicated, particularly for use in children. Using respiratory fluids (the liquid present in the lumen of the airways and alveoli) to estimate blood glucose levels indirectly is one potential method. Glucose concentrations in respiratory fluids are typically low, maintained by the equilibrium between paracellular leakage of glucose from the lung interstitium and active cotransport of glucose by epithelial cells. Measurement of glucose in respiratory fluid by collection of exhaled breath condensate is therefore a potentially clinically useful method of estimating blood glucose levels if it can be shown that there is good agreement between these values. This article reviews the research in this area.

Recent advances in the prevention of hypoglycemia in type 1 diabetes

Iatrogenic hypoglycemia is one of the chief barriers to optimal glycemic control in people with type 1 diabetes (T1D). As a common contributor to morbidity and mortality in T1D, severe hypoglycemia (SH) is also a major fear for people with T1D and their families. Consequently, fear of hypoglycemia and hypoglycemia-avoidant behaviors are predominant limiting factors in achieving euglycemia in people with T1D. Nocturnal SH and hypoglycemia unawareness are prevalent obstacles in the detection of hypoglycemia which further impair the prevention and treatment of SH. Various strategies and technologies have already been developed to help detect and prevent hypoglycemia, including improved patient education, frequent self-monitoring of blood glucose levels, the use of rapid-acting and basal insulin analogs, continuous subcutaneous insulin infusion therapy, exercise-related insulin modifications, and continuous glucose monitors. The efficacy of these methods is well established, but further advances are still needed. The purpose of this review is to describe these currently available methods and to emphasize recent progress related to the prevention of hypoglycemia in T1D.

Periodontitis in non-smoking type 1 diabetic adults: a cross-sectional study

AIM

To compare levels of periodontitis in non-smoking type 1 diabetic patients and controls.

MATERIAL AND METHODS

Type 1 diabetic patients, aged 20-55 years, were recruited from outpatient clinics at five hospitals in Glasgow, UK. Control subjects were recruited from physiotherapy clinics, using the buddy system and through an advertisement in a free newspaper. The primary outcome was severe periodontitis defined by clinical attachment level ≥6 mm on ≥1 tooth.

RESULTS

There were 34 well controlled patients (HbA1c ≤ 7.5%), 169 poorly controlled patients and 112 non-diabetic subjects. Prevalence of severe periodontitis was higher in all type 1 diabetic patients [24.1% (95% CI: 18.4-30.6%)] and poorly controlled patients [27.2% (20.7-34.6%)] than in controls [20.5% (13.5-29.2%)]. The fully adjusted odds ratios (ORs) in never smokers comparing the whole diabetic group, and the poorly controlled group, with the control group were 1.35 [0.66-2.8] (p = 0.41) and 1.58 [0.75-3.33] (p = 0.23), respectively. Mean clinical attachment level was higher in all type 1 diabetic and poorly controlled patients than in controls (both p < 0.001).

CONCLUSIONS

These results indicate worse periodontal health in type 1 diabetic patients than in control subjects.

TRIAL REGISTRATION

This study was registered with the UKCRN, ID: 9314 and Scottish Diabetes Research Network registration number: 128.

Cluster analysis of self-monitoring blood glucose assessments in clinical islet cell transplantation for type 1 diabetes

OBJECTIVE

Cluster analysis was performed on the results of self-monitoring of blood glucose (SMBG) to discriminate islet graft function after islet cell transplantation (ICT) in patients with type 1 diabetes.

RESEARCH DESIGN AND METHODS

Eleven islet recipients were included in this study. The patients visited our clinic monthly after ICT and provided blood samples for fasting C-peptide (n = 270), which were used to evaluate islet graft function. They also provided their SMBG data through an automatic data collection system. The SMBG data for 3 days immediately before each clinic visit were evaluated using the following assessments: M value, mean amplitude of glycemic excursions, J index, index of glycemic control, average daily risk range, and glycemic risk assessment diabetes equation. The cluster analysis was performed for both SMBG assessments and samples. Multivariate logistic regression analysis was used to evaluate the clusters of SMBG for assessing islet graft function.

RESULTS

Analysis for SMBG assessments revealed five types of clusters, which showed similar patterns according to functional or dysfunctional islet graft phase. Two clusters, the euglycemia cluster (P < 0.001) and the hypoglycemia cluster (P = 0.001), were significant factors in the logistic model for islet graft function. The SMBG clusters had significant correlations with clinical graft indexes (P < 0.001).

CONCLUSIONS

Cluster analysis of SMBG data as part of an automated data quality system could allow discrimination of islet graft dysfunction after ICT. This approach should be considered for islet recipients.

The impact of non-severe hypoglycemic events on work productivity and diabetes management

OBJECTIVES

Hypoglycemia is a common complication of treatment with certain diabetes drugs. Non-severe hypoglycemic events (NSHEs) occur more frequently than severe events and account for the majority of total events. The objective of this multi-country study was to identify how NSHEs in a working population affect productivity, costs, and self-management behaviors.

METHODS

A 20-minute survey assessing the impact of NSHEs was administered via the Internet to individuals (≥ 18 years of age) with self-reported diabetes in the United States, United Kingdom, Germany, and France. The analysis sample consisted of all respondents who reported an NSHE in the past month. Topics included: reasons for, duration of, and impact of NSHE(s) on productivity and diabetes self-management.

RESULTS

A total of 1404 respondents were included in this analysis. Lost productivity was estimated to range from $15.26 to $93.47 (USD) per NSHE, representing 8.3 to 15.9 hours of lost work time per month. Among individuals reporting an NSHE at work (n = 972), 18.3% missed work for an average of 9.9 hours (SD 8.4). Among respondents experiencing an NSHE outside working hours (including nocturnal), 22.7% arrived late for work or missed a full day. Productivity loss was highest for NSHEs occurring during sleep, with an average of 14.7 (SD 11.6) working hours lost. In the week following the NSHE, respondents required an average of 5.6 extra blood glucose test strips. Among respondents using insulin, 25% decreased their insulin dose following the NSHE.

CONCLUSIONS

NSHEs are associated with substantial economic consequences for employers and patients. Greater attention to treatments that reduce NSHEs could have a major, positive impact on lost work productivity and overall diabetes management.

Hypoglycemia: an overview of fear of hypoglycemia, quality-of-life, and impact on costs

BACKGROUND

The clinical goal in the treatment of diabetes is to achieve good glycemic control. Tight glycemic control achieved with intensive glucose lowering treatment reduces the risk of long-term micro- and macro-vascular complications of diabetes, resulting in an improvement in quality-of-life for the patient and decreased healthcare costs. The positive impact of good glycemic control is, however, counterbalanced by the negative impact of an increased incidence of hypoglycemia.

METHODS

A search of PubMed was conducted to identify published literature on the impact of hypoglycemia, both on patient quality-of-life and associated costs to the healthcare system and society.

RESULTS

In people with type 1 or type 2 diabetes, hypoglycemia is associated with a reduction in quality-of-life, increased fear and anxiety, reduced productivity, and increased healthcare costs. Fear of hypoglycemia may promote compensatory behaviors in order to avoid hypoglycemia, such as decreased insulin doses, resulting in poor glycemic control and an increased risk of serious health consequences. Every non-severe event may be associated with a utility loss in the range of 0.0033-0.0052 over 1 year, further contributing to the negative impact.

LIMITATIONS

This review is intended to provide an overview of hypoglycemia in diabetes and its impact on patients and society, and consequently it is not a comprehensive evaluation of all studies reporting hypoglycemic episodes.

CONCLUSION

To provide the best possible care for patients and a cost-effective treatment strategy for healthcare decision-makers, a treatment that provides good glycemic control with a limited risk of hypoglycemia would be a welcome addition to diabetes management options.

Three-day continuous glucose monitoring for rapid assessment of hypoglycemic events and glycemic variability in type 1 diabetic patients

This study was to determine whether glycemic variability is related to hypoglycemic events in type 1 diabetic patients, and whether the hypoglycemic events during a short-term continuous glucose monitoring system (CGMS) period parallel those measured during a 4-week self-monitoring of blood glucose (SMBG) period. We also evaluated whether glycemic variability indexes from a short-term CGMS correlate with those from a 4-week SMBG. A total of 49 type 1 diabetic patients wore CGMS devices for 3 days. These patients also performed SMBG for 4 weeks. Several indexes from the CGMS data were compared with indexes from the SMBG data. Hypoglycemic events (glucose levels <70 mg/dL) that occurred during the 3-day CGMS and 4-week SMBG periods were evaluated and compared. Hypoglycemic events were detected in 33 patients (67%) during the 3-day CGMS period. The patients with hypoglycemic events had a significantly higher glycemic variability index divided by mean glucose of CGMS, and a higher number of hypoglycemic events during the 4-week SMBG, compared to those with non-hypoglycemic events during the 3-day CGMS period. The percentage of hypoglycemic events using the 3-day CGMS was correlated with that from the 4-week SMBG (r=0.49, P<0.05) and low blood glucose index (r=0.51, P<0.05). The glycemic variability indexes from the 4-week SMBG correlated with the glycemic variability indexes from the 3-day CGMS. The short-term CGMS appears to be clinically useful for rapidly assessing the risk of hypoglycemic events and glycemic variability.

The prevalence of self-monitoring of blood glucose and costs of glucometer strips in a nationwide cohort

OBJECTIVE

This study used nationwide data to determine the prevalence of self-monitoring of blood glucose (SMBG) among all non-institutionalized persons living in Norway and to estimate the prevalence of SMBG among diabetes patients, the frequency and cost of SMBG, and the use of different glucometers.

METHODS

This retrospective, descriptive study is based on data of sales of glucometer strips to non-institutionalized persons in Norway in 2008. The data included gender, age group, month of purchase, sales place, type of strips, number of packages dispensed, and cost of strips. Additionally, statistics on sales of insulin and oral antidiabetes medications were obtained from the Norwegian Prescription Database.

RESULTS

A total of 96,999 persons purchased strips, a prevalence of 2%. Approximately 70% of diabetes patients practiced SMBG. An average patient used 1.7 strips per day, and younger patients purchased more strips than older patients. Fewer than 50% of patients performed glucose measurements daily. One percent of patients used more than 10 strips daily and was accountable for 8% of total costs. Most patients used only one type of strips, but the number of strips purchased increased with the number of different strips. The average annual cost of strips was 446 euro per person.

CONCLUSIONS

Two percent of all non-institutionalized inhabitants and an estimated 70% of patients using diabetes medication purchased SMBG strips. A small percentage of the patients incurred a substantial proportion of the costs. This, along with the fact that over half of the patients monitor less than once per day, calls for tighter follow-up of diabetes patients.

A simple and promising tool to improve self-monitoring of blood glucose in patients with diabetes

AIM

To examine patient formation of implementation plans, a volitional strategy, and its influence on self-monitoring of blood glucose (SMBG).

METHODS

A randomized experimental-control design over a 2-week time period was used. The study population was diabetes patients with HbA1c >7% and requiring insulin therapy. Patients were recruited from a southeastern Michigan healthcare system. A self-administered intervention was designed to assist patients to formulate plans to perform SMBG. The primary outcome measure was SMBG rates. Three control groups were used to control for testing effects. Hypotheses were tested using ANOVA at a significance level of 0.05. SMBG was measured using a 2-week diary and two recall measures.

RESULTS

There were 402 patients with diabetes recruited for the study. Analyses indicated that making implementation plans increased SMBG rates as assessed by a diary and two recall measures. The patients in the experimental group checked their blood sugar up to 7.77 times more than the control groups (sig<0.05) over a 2-week time period as measured by the diary.

CONCLUSIONS

Patient behavior can be impacted by using an implementation planning tool. This technique can help improve patient self-monitoring behavior.