Identification and prediction of group-based glycemic control trajectories during the transition to adolescence

ROUTE-T1D: A behavioral intervention to promote optimal continuous glucose monitor use among racially minoritized youth with type 1 diabetes: Design and development

BACKGROUND

Type 1 diabetes management is often challenging during adolescence, and many youth with type 1 diabetes struggle with sustained and optimal continuous glucose monitor (CGM) use. Due to racial oppression and racially discriminatory policies leading to inequitable access to quality healthcare and life necessities, racially minoritized youth are significantly less likely to use CGM.

METHODS

ROUTE-T1D: Research on Optimizing the Use of Technology with Education is a pilot behavioral intervention designed to promote optimal CGM use among racially minoritized youth with type 1 diabetes. Intervention strategies include problem solving CGM challenges and promoting positive caregiver-youth communication related to CGM data.

RESULTS

This randomized waitlist intervention provides participants with access to three telemedicine sessions with a Certified Diabetes Care and Education Specialist. Caregiver participants are also connected with a peer-parent coach.

CONCLUSION

Hypothesized findings and anticipated challenges are discussed. Future directions regarding sustaining and optimizing the use of diabetes technology among racially minoritized pediatric populations are reviewed.

Humanistic burden of pediatric type 1 diabetes on children and informal caregivers: systematic literature reviews

BACKGROUND

Diagnosis of children with type 1 diabetes (T1D) imposes an unprecedented burden on children and their caregivers.

OBJECTIVE

To assess the burden of T1D on children and their informal caregivers, both after a recent diagnosis or after a longer duration of disease.

METHODS

A series of systematic literature reviews were performed to explore the burden of T1D on children with the disease and their primary informal caregivers, based on the time of diagnosis. After the extraction of the qualitative and quantitative data from the included studies, two literature-based conceptual frameworks were developed: on the burden of pediatric T1D on children, and on informal caregivers. A third conceptual framework on the shared burden of pediatric T1D on both children and informal caregivers as part of the same family unit was also developed.

RESULTS

The review of literature has identified a series of factors that affect the quality of life of children with T1D and their informal caregivers, with a direct impact on physical, emotional, and social outcomes. Generally, female patients and older adolescents experience more worry and stress that affects their quality of life. Other categories of factors affecting the child's and caregiver's burden include social, emotional, and physical factors, treatment-related and disease-related factors, as well as their coping abilities. Anxiety, depression, stress, and worry were commonly found among children and caregivers, starting with the diagnosis of T1D and continuing over time in relation to new challenges pertaining to aging or the disease duration.

CONCLUSION

T1D causes a significant burden to affected children and their caregivers, both independently and through transactional interaction within the family unit. Disease burden can be reduced by strengthening individuals for the benefit of the whole family.

Heterogeneity in glycaemic control in children and adolescents with type 1 diabetes: A latent class trajectory analysis of Danish nationwide data

AIMS

Suboptimal glycaemic control in children and adolescents with type 1 diabetes is prevalent and associated with increased risk of diabetes-related complications and mortality later in life. First, we aimed to identify distinct glycated haemoglobin (HbA1c) trajectories in children and adolescents (2-19 years) with type 1 diabetes. Second, we examined their associations with clinical and socio-demographic factors.

METHODS

Data were obtained from the Danish Registry of Childhood and Adolescent Diabetes (DanDiabKids) comprising all Danish children and adolescents diagnosed with type 1 diabetes from 1996 to 2019. Subgroups of distinct mean trajectories of HbA1c were identified using data-driven latent class trajectory modelling.

RESULTS

A total of 5889 children (47% female) had HbA1c measured a median of 6 times (interquartile range 3-8) and contributing to 36,504 measurements. We identified four mean HbA1c trajectories, referred to as 'Stable but elevated HbA1c' (83%), 'Increasing HbA1c' (5%), 'Late HbA1c peak' (7%), and 'Early HbA1c peak' (5%). Compared to the 'Stable but elevated HbA1c' group, the three other groups presented rapidly deteriorating glycaemic control during late childhood or adolescence, had higher HbA1c at study entry, and included fewer pump users, higher frequency of inadequate blood glucose monitoring, more severe hypoglycaemic events, lower proportions with Danish origin, and worse educational status of parents. The groups also represented significant differences by healthcare region.

CONCLUSIONS

Children and adolescents with type 1 diabetes experience heterogenous trajectories with different timings and magnitudes of the deterioration of HbA1c levels, although the majority follow on average a stable, yet elevated HbA1c trajectory. The causes and long-term health implications of these heterogenous trajectories need to be addressed.

Responses to the Strengths and Difficulties Questionnaire predict HbA1c trajectories in children and adolescents with type 1 diabetes: a population-based study

INTRODUCTION

We aimed to determine whether caregiver responses to the Strengths and Difficulties Questionnaire (SDQ) are predictive of HbA1c trajectory membership in children and adolescents with type 1 diabetes, when adjusting for covariates.

RESEARCH DESIGN AND METHODS

For a Danish 2009 national cohort of children and adolescents with type 1 diabetes, we analyzed yearly HbA1c follow-up data during 2010-2020 including sociodemographic data from Danish national registries. Using group-based trajectory modeling and multinomial logistic regression, we tested whether caregiver SDQ scores predicted HbA1c trajectory membership when adjusting for sex, age at diabetes diagnosis, diabetes duration, family structure, and caregiver education.

RESULTS

In total, 835 children and adolescents (52% females) with a mean (SD) age of 12.5 (3.3) years, and a mean diabetes duration of 5.2 (3.1) years, were included. Based on 7247 HbA1c observations, four HbA1c trajectories were identified: (1) 'on target, gradual decrease' (26%), (2) 'above target, mild increase then decrease' (41%), (3) 'above target, moderate increase then decrease' (24%), and (4) 'well above target, large increase then decrease' (9%). Higher SDQ total difficulties scores predicted trajectories 3 and 4 (p=0.0002 and p<0.0001, respectively). Regarding the SDQ subscale scores, emotional symptoms predicted trajectories 3 and 4, and conduct problems and hyperactivity/inattention predicted trajectories 2, 3, and 4. Single-parent family and low caregiver education level both predicted trajectories 3 and 4.

CONCLUSIONS

Caregiver SDQ responses and sociodemographic information may help detect children and adolescents with type 1 diabetes, who need intensive multidisciplinary medical and psychological interventions.

Effects of Parental Involvement on Glycemic Control in Adolescents With Type 1 Diabetes Mellitus: A Scoping Review

Type 1 diabetes mellitus (T1DM) is typically diagnosed in pediatric patients. Transitioning from supported management in childhood to self-management in adolescence is an important step. Parental psychosocial influence is a possible factor in adolescents' disease control. This review summarized the effects of parental involvement on glycemic control in adolescents with T1DM by focusing on hemoglobin A1c (HgbAIc). A scoping review per the Guidance for Systematic Scoping Reviews was conducted with the following inclusion criteria: (a) studies in English, (b) focused on adolescents with T1DM, (c) outcomes included HgbAIc, and (d) focused on parental influence of children with T1DM. Of 476 articles, 14 were included. The study outcomes were classified based on direct or indirect influence. "Parental support for adherence" and "parental conflict" significantly affected HgbAIc control. This study provides current evidence on parental influence on glycemic control in adolescents.

Executive Functioning, Daily Self-Regulation, and Diabetes Management while Transitioning into Emerging Adulthood

BACKGROUND

Executive functioning (EF) predicts better Type 1 diabetes (T1D) management in the high-risk years after high school, but the daily self-regulation processes involved are unclear.

PURPOSE

To examine whether EF is associated with daily self-regulation that minimizes one's exposure or buffers adverse reactions to daily diabetes problems, and to determine whether these patterns become stronger during the transition out of high school.

METHODS

A measurement burst design with convenience sampling was used. Seniors in high school with T1D (N = 207; 66% female) completed self-report (i.e., Behavioral Rating Inventory of Executive Functioning) and performance measures of EF (i.e., Delis-Kaplan Executive Function System). A 14-day daily diary assessing self-regulation failures, diabetes problems, affect, and indicators of diabetes management was completed at baseline and 1 year later.

RESULTS

Correlations and multilevel modeling were conducted. Lower self-reported EF problems were associated with lower average levels of daily self-regulation failures, and these variables were associated with fewer daily diabetes problems. In contrast, better EF performance was unrelated to average daily self-regulation failures, and was unexpectedly associated with more frequent diabetes problems in year 2. Equally across years, on days participants reported lower than their average levels of daily self-regulation failures, they had fewer diabetes problems, regardless of EF. On days with lower than average diabetes problems, participants reported better diabetes management indicators. EF generally did not buffer daily associations in either year.

CONCLUSIONS

Regardless of EF, promoting daily self-regulation may prevent diabetes problems and promote T1D management in daily life at this high-risk transitional time.

Adherence in Diabetes Questionnaire (ADQ) score as predictor of 11-year HbA1c trajectories in children and adolescents with type 1 diabetes: A population-based longitudinal study

AIMS

To identify 11-year HbA_1c trajectories in children/adolescents with type 1 diabetes and determine whether baseline caregiver- and/or child/adolescent-reported Adherence in Diabetes Questionnaire (ADQ) scores and multiple covariates predict HbA_1c trajectory membership.

METHODS

For a 2009 population-based cohort of children/adolescents with type 1 diabetes, we analyzed HbA_1c follow-up (2010-2020) data from Danish diabetes registries. HbA_1c trajectories were identified with group-based trajectory modeling. Using multinomial logistic regression, we tested whether ADQ scores predicted trajectory membership when adjusting for sex, age at diabetes diagnosis, diabetes duration, family structure, and caregiver education.

RESULTS

For 671 children/adolescents (10-17 years at baseline) with 5644 HbA_1c observations over 11 years, four trajectories/groups were identified: 1) "on target, gradual decrease" (27%), 2) "above target, mild increase then decrease" (39%), 3) "above target, moderate increase then decrease" (25%), and 4) "well above target, large increase then decrease" (9%). Using group one as the reference, lower caregiver-reported ADQ scores predicted group 2, 3, and 4 membership. Lower child/adolescent-reported ADQ scores predicted group 3 and 4 membership. Low caregiver education predicted group 3 and 4 membership. Single-parent status predicted group 4 membership.

CONCLUSIONS

ADQ scores and socio-demographics may serve as tools to predict glycemic control in youth with type 1 diabetes.

Glycemic Control Trajectories and Risk of Perinatal Complications Among Individuals With Gestational Diabetes

IMPORTANCE

Glycemic control is the cornerstone of gestational diabetes management. Glycemic control trajectories account for differences in longitudinal patterns throughout pregnancy; however, studies on glycemic control trajectories are scarce.

OBJECTIVE

To examine whether glycemic control trajectories from gestational diabetes diagnosis to delivery were associated with differential risk of perinatal complications.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study included individuals with gestational diabetes with longitudinal electronic health record data from preconception to delivery who received prenatal care at Kaiser Permanente Northern California (KPNC) and were enrolled in KPNC's telemedicine-based gestational diabetes care program between January 2007 and December 2017. Data analysis was conducted from September 2021 to January 2022.

EXPOSURES

Glycemic control trajectories were derived using latent class modeling based on the American Diabetes Association's recommended self-monitoring of blood glucose measurements. Optimal glycemic control was defined as at least 80% of all measurements meeting the targets at KPNC clinical settings.

MAIN OUTCOMES AND MEASURES

Multivariable Poisson regression models were used to estimate the associations of glycemic control trajectories with cesarean delivery, preterm birth, shoulder dystocia, large- and small-for-gestational-age, and neonatal intensive care unit admission and stay of 7 days or longer.

RESULTS

Among a total of 26 774 individuals (mean [SD] age, 32.9 [5.0] years; 11 196 Asian or Pacific Islander individuals [41.8%], 1083 Black individuals [4.0%], 7500 Hispanic individuals [28.0%], and 6049 White individuals [22.6%]), 4 glycemic control trajectories were identified: stably optimal (10 528 individuals [39.3%]), rapidly improving to optimal (9151 individuals [34.2%]), slowly improving to near-optimal (4161 individuals [15.5%]), and slowly improving to suboptimal (2934 individuals [11.0%]). In multivariable models with the rapidly improving to optimal trajectory group as the reference group, glycemic control trajectories were associated with perinatal complications with a gradient across stably optimal to slowly improving to suboptimal. For individuals in the stably optimal trajectory group, there were lower risks of cesarean delivery (adjusted relative risk [aRR], 0.93 [95% CI, 0.89-0.96]), shoulder dystocia (aRR, 0.75 [95% CI, 0.61-0.92]), large-for-gestational age (aRR, 0.74 [95% CI, 0.69-0.80]), and neonatal intensive care unit admission (aRR, 0.90 [95% CI, 0.83-0.97]), while for patients in the slowly improving to suboptimal glycemic control trajectory group, risks were higher for cesarean delivery (aRR, 1.18 [95% CI, 1.12-1.24]; (P for trend < .001), shoulder dystocia (aRR, 1.41 [95% CI, 1.12-1.78]; P for trend < .001), large-for-gestational-age (aRR, 1.42 [95% CI, 1.31-1.53]; P for trend < .001), and neonatal intensive care unit admission (aRR, 1.33 [95% CI, 1.20-1.47]; P for trend < .001). The risk of small-for-gestational-age was higher in patients in the stably optimal group (aRR, 1.10 [95% CI, 1.02-1.20]) and lower in the slowly improving to suboptimal group (aRR, 0.63 [95% CI, 0.53-0.75]).

CONCLUSIONS AND RELEVANCE

These findings suggest that slowly improving to near-optimal and slowly improving to suboptimal glycemic control trajectories were associated with increased risk of perinatal complications. Future interventions should help individuals achieve glycemic control early after gestational diabetes diagnosis and throughout pregnancy to decrease the risk of perinatal complications.

Heterogeneous long-term trajectories of glycaemic control in type 1 diabetes

AIMS

We aimed to identify long-term HbA1c trajectories and examine associated characteristics in an observational, childhood-onset (<17 years) type 1 diabetes cohort.

METHODS

Data are from the Epidemiology of Diabetes Complications study, comprising 405 participants with ≥2 of seven possible HbA1c measurements over follow-up (1988-2013) and available DNA (baseline mean diabetes duration 21 years, 53% men). HbA1c trajectories were estimated using latent class growth models. Baseline and change in participant characteristics were compared across trajectories.

RESULTS

Five HbA1c trajectories were identified: low (51%), intermediate stable (22%), improved (19%), high stable (6%), and worsened (2%; not included in analyses). Age, diabetes duration, diabetes onset age, and sex did not differ across trajectories. Characteristics did not differ significantly between intermediate stable and low trajectories at baseline, though albumin excretion rate (AER, p = 0.0002) and estimated glomerular filtration rate (eGFR, p = 0.001) worsened slightly more in intermediate stable over time. Improved and high stable trajectories had higher baseline LDL-c (p = 0.002 and 0.003, respectively). Improved trajectory increased median self-monitoring of blood glucose from <1 to 3.5 times/day (p < 0.0001) and had larger LDL-c improvement (p = 0.004) but greater worsening of AER (p < 0.0001) and eGFR (p < 0.0001) than low. The A allele of rs12970134 (near MC4R) was associated with improved (p = 0.0003) or high stable (p = 0.001) HbA1c trajectory, both patterns with high baseline HbA1c.

CONCLUSIONS

Long-term HbA1c trajectories were primarily associated with modifiable factors in this type 1 diabetes cohort. The intermediate stable pattern had a risk factor profile that suggests some protection against adverse metabolic effects of chronic hyperglycaemia, warranting further study.

Hemoglobin A1c Patterns of Youth With Type 1 Diabetes 10 Years Post Diagnosis From 3 Continents

OBJECTIVES

Distinct hemoglobin A1c (HbA1c) trajectories during puberty are identified in youth with established type 1 diabetes (T1D). We used data from 3 international registries to evaluate whether distinct HbA1c trajectories occur from T1D onset.

METHODS

Participants were <18 years old at diagnosis with at least 1 HbA1c measured within 12 months post diagnosis, along with ≥3 duration-year-aggregated HbA1c values over 10 years of follow-up. Participants from the Australasian Diabetes Data Network (n = 7292), the German-Austrian-Luxembourgian-Swiss diabetes prospective follow-up initiative (Diabetes Patienten Verlaufsdokumentation) (n = 39 226) and the US-based Type 1 Diabetes Exchange Clinic Registry (n = 3704) were included. With group-based trajectory modeling, we identified unique HbA1c patterns from the onset of T1D.

RESULTS

Five distinct trajectories occurred in all 3 registries, with similar patterns of proportions by group. More than 50% had stable HbA1c categorized as being either low stable or intermediate stable. Conversely, ∼15% in each registry were characterized by stable HbA1c >8.0% (high stable), and ∼11% had values that began at or near the target but then increased (target increase). Only ∼5% of youth were above the target from diagnosis, with an increasing HbA1c trajectory over time (high increase). This group differed from others, with higher rates of minority status and an older age at diagnosis across all 3 registries (P ≤ .001).

CONCLUSIONS

Similar postdiagnostic HbA1c patterns were observed across 3 international registries. Identifying the youth at the greatest risk for deterioration in HbA1c over time may allow clinicians to intervene early, and more aggressively, to avert increasing HbA1c.

Pathways of emotional autonomy, problem-solving ability, self-efficacy, and self-management on the glycemic control of adolescents with type 1 diabetes: A prospective study

This prospective study tested a model to depict associations between a number of individual characteristics and 6-month glycated hemoglobin (HbA1c) levels in adolescents with type 1 diabetes (T1D). Adolescents (N = 232) aged 10-19 years with T1D were recruited from a medical center in Taiwan. Demographic characteristics, emotional autonomy, problem-solving ability, self-efficacy at baseline, and self-management information three months after baseline were collected using a self-reported questionnaire. HbA1c levels 6 months after study commencement were obtained from medical records. Structural equation modeling was used to test the model. Higher baseline self-efficacy and self-management at 3 months were directly associated with lower 6-month HbA1c levels. Higher baseline problem-solving ability and self-efficacy were directly associated with higher 3-month self-management, and higher baseline problem-solving ability was directly associated with higher baseline self-efficacy. Higher baseline emotional autonomy was directly associated with lower 6-month HbA1c levels but indirectly associated with higher 6-month HbA1c levels through the mediation of lower problem-solving ability, self-efficacy, and 3-month self-management. Findings indicate that improving self-management is essential to improving subsequent glycemic control, which might be achieved by enhancing problem-solving ability and self-efficacy. Strengthening problem-solving ability could diminish the negative impact of emotional autonomy on subsequent glycemic control in adolescents with T1D.

Effects of family and neighborhood risks on glycemic control among young black adolescents with type 1 diabetes: Findings from a multi-center study

While individual and family risk factors that contribute to health disparities in children with type 1 diabetes have been identified, studies on the effects of neighborhood risk factors on glycemic control are limited, particularly in minority samples. This cross-sectional study tested associations between family conflict, neighborhood adversity and glycemic outcomes (HbA1c) in a sample of urban, young Black adolescents with type 1 diabetes(mean age = 13.4 ± 1.7), as well as whether neighborhood adversity moderated the relationship between family conflict and HbA1c. Participants (N = 128) were recruited from five pediatric diabetes clinics in two major metropolitan US cities. Diabetes-related family conflict was measured via self-report questionnaire (Diabetes Family Conflict Scale; DFCS). Neighborhood adversity was calculated at the census block group level based on US census data. Indictors of adversity were used to calculate a neighborhood adversity index (NAI) for each participant. Median family income was $25,000, suggesting a low SES sample. In multiple regression analyses, DFCS and NAI both had significant, independent effects on glycemic control (β = 0.174, P = 0.034 and β = 0.226 P = 0.013, respectively) after controlling for child age, family socioeconomic status and insulin management regimen. Tests of effects of the NAI and DFCS interaction on HbA1c found no significant moderating effects of neighborhood adversity. Even within contexts of significant socioeconomic disadvantage, variability in degree of neighborhood adversity predicts diabetes-related health outcomes in young Black adolescents with type 1 diabetes. Providers should assess social determinants of health such as neighborhood resources that may impact adolescents' ability to maintain optimal glycemic control.

Parent Perspectives on Educational and Psychosocial Intervention for Recent-Onset Type 1 Diabetes in Their School-Age Child: A Qualitative Study

OBJECTIVE

The recent-onset period of type 1 diabetes (T1D) in early school-age children should include comprehensive, parent-focused T1D education as well as family-centered resources and support to help with adjustment. Here, we present parent/caregiver perspectives on specific areas of concern during the recent-onset period of T1D and their preferred timing for different topics related to T1D education.

METHODS

Parents/caregivers of 5- to 9-year-old children with T1D completed a card-sorting task and qualitative interview to describe ongoing areas of concern and preferred educational topics during the first year after T1D diagnosis.

RESULTS

Thirteen parents/caregivers (aged 35.1 ± 6.9 years) of a child with T1D (aged 8.9 ± 0.8 years, 11.3 ± 7.0 months post-diagnosis) completed the card-sorting task, and 11 completed the qualitative interview. Parents/caregivers endorsed four preferred stages of education: basic education and T1D survival skills during month 1 post-diagnosis, application and practice of T1D skills from months 1-3, access to community supports to cope with anxiety and distress from months 3-6, and support to build autonomy and manage burnout beyond month 6 post-diagnosis. Parents/caregivers endorsed four main themes for ongoing concerns: anxiety, autonomy, distress, and support.

CONCLUSION

Parents endorsed four time points for education and psychosocial services within the first year of a T1D diagnosis. Parents/caregivers may benefit the most from psychosocial interventions 3-6 months post-diagnosis, once they have had sufficient time to develop basic T1D management skills. These findings support the need for regular parent psychosocial screening and access to scalable psychosocial interventions in the first year post-diagnosis of T1D.

A systematic review of parenting interventions for child chronic health conditions

This systematic review summarizes the parenting intervention literature for parents of children with chronic health conditions and evaluates intervention effects on parenting (parenting skills and parenting efficacy) and child (behaviour, illness severity/control and quality of life) outcomes. Systematic searches using seven electronic databases (including CINHAL, MEDLINE and PsycINFO) were used to identify relevant papers published in English between 1997 and 2017, and reference lists were searched for additional relevant articles. Ten papers reporting on eight separate studies met inclusion criteria: three studies evaluated stand-alone parenting interventions, while the remaining five studies included parenting components in broader interventions that also targeted medically oriented aspects of illness management. Results suggest that parenting interventions may lead to improved parent self-efficacy, parenting behaviour, illness severity/control, child quality of life and child behaviour; however, intervention effects were mixed and confined to parent-report outcome measures. A paucity of studies using rigorous randomized controlled trial study designs limits the conclusions that can be drawn regarding intervention efficacy. Achieving adequate enrolment and retention of families in parenting intervention trials appears to be problematic within these clinical groups. Larger samples and more diverse clinical populations will support the reliability of future evaluations of parenting interventions in this context and improve generalizability of results.

The Self-Management Experiences of Adolescents with Type 1 Diabetes: A Descriptive Phenomenology Study

Many adolescents with type 1 diabetes experience challenges in achieving good glycemic control and have insufficient understanding in executing interventions for glycemic control. This study aimed to understand self-management experiences of adolescents with type 1 diabetes in Taiwan. In this descriptive phenomenological study, we conducted in-depth interviews with 18 adolescents with type 1 diabetes from the pediatric outpatient clinic of a medical center. Data were analyzed using the Colaizzi's method. Four themes were identified: (1) misconception regarding self-management of blood glucose; (2) conflict between depending on and breaking away from parental assistance for glycemic control; (3) encounter with disruptions in glycemic control regimen due to the presence of schedule changes; and (4) lack of motivation to achieve good glycemic control. The findings indicated that the misconceptions of adolescents with type 1 diabetes about managing glycemic levels resulted from an insufficient understanding of self-management of diabetes. In Taiwan, the heavy emphasis of academic achievement and changes of schedules during breaks tended to disrupt the regimen for glycemic control. Healthcare professionals are encouraged to provide individualized education focusing on the adolescents' misconceptions regarding self-management of diabetes.

Featured Article: Comparison of Diabetes Management Trajectories in Hispanic versus White Non-Hispanic Youth with Type 1 Diabetes across Early Adolescence

OBJECTIVE

Ethnic minority youth with type 1 diabetes (T1D) often have poorer glycemic control and lower rates of adherence compared to White Non-Hispanic (WNH) youth. Variables such as family conflict, autonomy support, and youth regimen responsibility have been shown to change over adolescence and impact diabetes management. However, these factors have been investigated in predominantly White samples. Few studies have examined potential differences in these variables and their trajectories for Hispanic youth over early adolescence.

METHODS

Youth with T1D (178 WNH and 33 Hispanic youth participants), as well as their maternal caregivers (174 WNH and 32 Hispanic maternal caregivers), completed measures of diabetes-specific autonomy support, diabetes-related family conflict, regimen responsibility, and blood glucose monitoring frequency at 4 timepoints over a 3-year period.

RESULTS

At baseline, Hispanic youth had significantly poorer glycemic control, more family conflict, and fewer blood glucose checks on average compared to WNH youth. Similar to WNH youth, Hispanic youth have increasing independence for regimen tasks and decreasing parent autonomy support during this developmental period. However, while Hispanic youth had worsening diabetes management during early adolescence (as did WNH youth), Hispanic parents reported a more gradual change in youth's diabetes management over early adolescence.

CONCLUSIONS

This study presents an important contribution to the existing literature on youth with T1D. Findings suggest potential strengths and targets for Hispanic youth navigating diabetes management during the adolescent period. It is important to continue to investigate the trajectories of ethnic minority youth with diabetes.

Adaptation of an Evidence-Based Diabetes Management Intervention for Delivery in Community Settings: Findings From a Pilot Randomized Effectiveness Trial

Objective

To adapt an evidence-based intervention targeting diabetes management in adolescents with poorly controlled type 1 diabetes for use in a community setting by community health workers (CHWs) and to conduct pilot testing of the new intervention, REACH for Control (RFC). The study was conducted as a collaboration between university researchers and a federally qualified health center. Methods In a pilot effectiveness trial, feasibility and acceptability of RFC were evaluated based on participant enrollment, treatment dose, and consumer satisfaction. RFC effects on adolescent adherence, health outcomes, and quality of life were also assessed. The trial used a parallel group design. Families were randomized to 6 months of RFC plus standard medical care (n = 26) or standard care (SC) only (n = 24). Data were collected at baseline and 7-month posttest. A mixed-methods approach was used to analyze data.

Results

Qualitative analyses suggested that caregivers viewed RFC and delivery of a home-based intervention by CHWs positively. Furthermore, adolescents who received RFC had statistically significant (p = .05) and clinically meaningful improvements in hemoglobin A1c (HbA1c) (0.7%) and reported significant improvements in quality of life from baseline to follow-up (p = .001). No significant changes were found for adolescents in standard medical care. However, while dose of primary intervention session delivered was acceptable, dose of follow-up sessions used for skills practice was low.

Conclusions

Results provide preliminary support for RFC's acceptability and effectiveness to improve health status and quality of life when used in community settings serving high-risk, low-income families. Additional testing in a full-scale effectiveness trial appears warranted.

Blood Glucose Monitoring Before and After Type 1 Diabetes Clinic Visits

Objective

To determine patterns of blood glucose monitoring in children and adolescents with type 1 diabetes (T1D) before and after routine T1D clinic visits.

Methods

Blood glucose monitoring data were downloaded at four consecutive routine clinic visits from children and adolescents aged 5-18 years. Linear mixed models were used to analyze patterns of blood glucose monitoring in patients who had at least 28 days of data stored in their blood glucose monitors.

Results

In general, the frequency of blood glucose monitoring decreased across visits, and younger children engaged in more frequent blood glucose monitoring. Blood glucose monitoring increased before the T1D clinic visits in younger children, but not in adolescents. It declined after the visit regardless of age.

Conclusions

Members of the T1D care team need to consider that a T1D clinic visit may prompt an increase in blood glucose monitoring when making treatment changes and recommendations. Tailored interventions are needed to maintain that higher level of adherence across time.

Psychological Considerations in Pediatric Chronic Illness: Case Examples

Despite significant gains in survival rates for pediatric patients and adolescents/young adults (AYA) with chronic illness, patients in this vulnerable age group are also at an increased risk for developing one or more adverse effects related to their disease, treatment, or maladaptive health behaviors. Maladaptive health behaviors ultimately increase the risk for developing adverse effects, including: increased rates of morbidity and mortality, impaired physical functioning, increased fatigue, obesity, increased psychological distress, and poor quality of life. With close attention including participation in preventive and therapeutic health promotion interventions, problematic health behaviors can be mitigated and ultimately prevented over time. It is well known that improved psychological functioning and adaptive coping can result in improved health status. The present paper provides four case examples illustrating various psychological interventions in pediatric chronic illness. As evidenced in the four case examples, pediatric psychologists provide comprehensive interventions for patients with acute and chronic medical conditions through the use of health promotion interventions, adherence and self-management promotion, cognitive behavioral therapy, behavioral therapy, medical coping, parent training, and motivational interviewing. Our case series demonstrates that for the most impactful behavior change to occur, a combination of interventions is often the most effective.

Factors predicting poor glycemic control in the first two years of childhood onset type 1 diabetes in a cohort from East London, UK: Analyses using mixed effects fractional polynomial models

BACKGROUND/OBJECTIVE

Poor early glycemic control in childhood onset type 1 diabetes (T1D) is associated with future risk of acute and chronic complications. Our aim was to identify the predictors of higher glycated hemoglobin (HbA1c) within 24 months of T1D diagnosis in children and adolescents.

METHODS

Mixed effects models with fractional polynomials were used to analyze longitudinal data of patients <19 years of age, followed from T1D diagnosis for up to 2 years, at three diabetes clinics in East London, United Kingdom.

RESULTS

A total of 2209 HbA1c observations were available for 356 patients (52.5% female; 64.4% non-white), followed from within 3 months of diagnosis during years 2005 to 2015, with a mean ± SD of 6.2 ± 2.5 HbA1c observations/participant. The mean age and HbA1c at diagnosis were 8.9 ± 4.3 years and 10.7% ±4.3% (or expressed as mmol/mol HbA1c mean ± SD 92.9 ± 23.10 mmol/mol) respectively. Over the 2 years following T1D diagnosis, HbA1c levels were mostly above the National Institute for Health, Care and Excellence (NICE), UK recommendations of 7.5% (<58 mmol/mol). Significant (P < .05) predictors of poorer glycemic control were: Age at diagnosis (12-18 years), higher HbA1c at baseline (>9.5%, ie, >80 mmol/mol), clinic site, non-white ethnicity, and period (pre-year 2011) of diagnosis. Additionally in univariable analyses, frequency of clinic visits, HbA1c at diagnosis, and type of insulin treatment regimen showed association with poor glycemic control (P < .05).

CONCLUSIONS

Major risk factors of poorer glycemic control during 3-24 months following childhood onset T1D are: diagnosis prior to 2011, higher HbA1c levels at baseline, age at diagnosis, non-white ethnicity, and clinic site.

Trajectory Analysis of Glycemic Control in Adolescents with Type 1 Diabetes Mellitus at Dammam Medical Complex, Saudi Arabia

BACKGROUND

Saudi Arabia is reported to have the highest number of children and adolescents with T1DM. However, data concerning glycemic control during adolescence are lacking.

OBJECTIVES

To determine glycemic control at transition stage from pediatric to adult clinics, determine HBA1c patterns during follow-up, and identify any clinical or demographic variables that may predict a distinctive glycemic pattern.

DESIGN

Observational retrospective study. Setting. Dammam Medical Complex, secondary care hospital. Patients and Method. Adolescents aged ≥12 years, with HbA1c recorded at least once a year over 4 years of follow-up, were eligible for inclusion. A trajectory analysis from 2008 to 2019 was conducted, using latent class growth modelling (LCGM), and two-sample t-tests and Fisher's exact tests were conducted to determine whether there was a statistically significant difference in demographic and clinical variables. Sample Size. 44 patients.

RESULTS

61.36% were referred from pediatric clinics, and 84% were on multiple insulin daily injections. For the trajectory prediction, two groups were identified. Group 1 comprised 71.7%, had high HbA1c values at age 13 (HbA1c, 11.28%), and had a significant and stable decrease in HbA1c values with age (-0.32, p < 0.00). Group 2 comprised 28.2%, showed poor HbA1c values at age 13 (HbA1c, 13.28%), and showed increase in HbA1c values slightly by age 15, which then steadily decreased with age (-0.27). Results indicated that the initial HBA1c value was a significant predictor for group trajectory (p=0.01), while the remaining variables did not have any significance.

CONCLUSION

Our study identified two groups with poorly controlled diabetes; however, the first group performed relatively better than the second group. Both groups almost doubled their targets, with a trend towards HbA1c reduction by the age of 19 in both groups. Limitations. Retrospective study with convenient, small sample size.

An eHealth Program for Parents of Adolescents With T1DM Improves Parenting Stress: A Randomized Control Trial

PURPOSE

The purpose of this study was to evaluate the short-term effects of the Type 1 Teamwork program for parents of adolescents with type 1 diabetes mellitus (T1DM) on the primary outcome of psychosocial stress.

METHODS

The study was a randomized wait-list control trial evaluating an eHealth program to reduce parenting stress around T1DM management during adolescence through interactive sessions on the safe transfer of responsibility, positive communication, and stress management. The primary outcome was psychosocial stress (parenting stress specific to child illness and general stress). Secondary outcomes included depressive and anxiety symptoms, parent support for adolescent autonomy, family conflict, and adolescent metabolic control (A1C). Data were collected at baseline, 3 months, and 6 months online. Mixed-model analyses were conducted, using intent-to-treat procedures.

RESULTS

Parents (n = 162) had a mean age of 45.6 (±5.3) years, were 98% female, 91% white, 91% married/partnered, 51% of high income, and geographically dispersed around the United States. Parents reported that adolescents had a mean A1C of 7.9% (±1.2%) and T1DM duration of 5.08 (±3.62) years. At 6 months, parents in the Type 1 Teamwork group demonstrated less parenting stress compared with the control group. There were no differences between groups on general stress or secondary outcomes. Attrition at 6 months was 32% in the treatment group and 11% in the control group.

CONCLUSIONS

An eHealth program for parents of adolescents with T1DM improves parenting stress in a sample of parents from across the United States.

Five heterogeneous HbA1c trajectories from childhood to adulthood in youth with type 1 diabetes from three different continents: A group-based modeling approach

OBJECTIVES

Only a fraction of youth meet established targets for glycemic control; many experience deteriorating control over time. We compared trajectories of hemoglobin A1c (HbA1c) among youth from three trans-continental type 1 diabetes (T1D) registries and identified clinical variables associated with the odds of following increasing vs stable trajectories.

RESEARCH DESIGN AND METHODS

Analyses included longitudinal data from 15 897 individuals age 8 to 18 with T1D for at least 2 years and HbA1c measurements in at least 5 years during the observation period. Cohorts were selected from Australasian Diabetes Data Network (ADDN; Australia), German/Austrian/Luxembourgian Diabetes-Patienten-Verlaufsdokumentation initiative (DPV; Germany/Austria/Luxembourga), and the T1D Exchange Clinic Network (T1DX; US) clinic registries. Group-based trajectory modeling and multivariable logistic regression identified unique HbA1c trajectories and their predictors.

RESULTS

Five heterogeneous trajectories of glycemic control in each registry were identified: low, intermediate, high stable; intermediate and high increasing. The overall HbA1c level for each trajectory group tended to be lowest in the DPV, higher in the ADDN, and highest in the T1DX. The absolute level of HbA1c and the proportion of individuals within each trajectory varied across registries: 17% to 22% of individuals followed an increasing trajectory. Compared with maintaining a stable trajectory, following an increasing trajectory was significantly associated with ethnic minority status, lower height z-score, higher BMI z-score, insulin injection therapy, and the occurrence of severe hypoglycemia; however, these factors were not consistent across the three registries.

CONCLUSIONS

We report the first multinational registry-based comparison of glycemic control trajectories among youth with T1D from three continents and identify possible targets for intervention in those at risk of an increasing HbA1c trajectory.

Trajectories of hemoglobin A1c and body mass index z-score over four decades among 2 to 18 year olds with type 1 diabetes

OBJECTIVES

To determine trajectories of glycemic control and body mass index (BMI) z-score in a large pediatric sample with type 1 diabetes (T1D) over a 38-year period, and to evaluate sex differences and temporal changes in the prevalence of these trajectories.

METHODS

We conducted a longitudinal, retrospective study of 7002 2 to 18 year olds with T1D followed between 1978 and 2016 at a single center. Group-based modeling was used to identify trajectories for hemoglobin A1c (HbA1c) and BMI z-score. Multinomial logistic regression identified predictors of membership to less favorable glycemic trajectories.

RESULTS

Group-based modeling yielded 5 HbA1c trajectories. A total of 86% of the sample fell within 3 trajectories that were largely stable across childhood and adolescence, and 14% fell within 2 trajectories characterized by marked deterioration beginning in pre-adolescence. Girls were more likely to be in the HbA1c trajectory with the highest starting HbA1c and significant deterioration during adolescence, and in the highest two BMI z-score trajectories. Patients with non-white race had the highest odds of belonging to a less favorable HbA1c trajectory. Prevalence of the high stable HbA1c trajectory decreased and prevalence of the low stable HbA1c trajectory increased over the study period.

CONCLUSIONS

A minority of youth with T1D experienced deterioration of glycemic control during adolescence. Girls were more likely to belong to the worst HbA1c trajectory and to BMI z-score trajectories in the overweight/obese range, which may increase cardiometabolic risk. Addressing racial/ethnic disparities in glycemic control should remain a priority. Advances in T1D management correlated with favorable shifts in HbA1c trajectory prevalence.

Diabetes and Behavior in the 21st Century: Things That Make You Go "Hmmm . . . "

Editor's Note: This article is adapted from the address Dr. Wysocki delivered as the recipient of the American Diabetes Association's Richard R. Rubin Award for 2018. This award recognizes a behavioral researcher who has made outstanding, innovative contributions to the study and understanding of the behavioral aspects of diabetes in diverse populations. Dr. Wysocki delivered the address in June 2018 at the association's 78th Scientific Sessions in Orlando, Fla.

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

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

Executive Function Predicting Longitudinal Change in Type 1 Diabetes Management During the Transition to Emerging Adulthood

OBJECTIVE

The objective of this study was to examine 1) whether teens' glycemic control and adherence to type 1 diabetes treatment regimen worsen during the transition from late adolescence to emerging adulthood, and 2) whether teens' executive function (EF), as measured by performance and self-reported problems with EF, is predictive of these changes (after controlling for general intelligence).

RESEARCH DESIGN AND METHODS

High school seniors with type 1 diabetes (N = 236; mean age 17.74 years) were assessed at three yearly time points. At baseline, during the senior year of high school, participants completed a self-report measure of problems with EF and performance-based measures of EF and general intelligence (IQ). Glycemic control was determined on the basis of results collected from HbA1c assay kits, and teens reported their adherence at all three time points.

RESULTS

HbA1c increased significantly across the three time points and adherence declined. EF performance was not associated with adherence or HbA1c at baseline, nor with changes in adherence over time. However, better EF performance predicted slower increases in HbA1c over time (i.e., slope) while controlling for IQ. Teens' self-reported problems with EF were associated with worse glycemic control and poorer adherence at baseline (i.e., intercept), but they did not predict changes in either HbA1c or adherence over time (i.e., slope).

CONCLUSIONS

Abilities involved in performance on EF tests may be one resource for maintaining better glycemic control during the transition to emerging adulthood. Assessment of such EF abilities may allow for the identification of individuals who are most at risk for deterioration of glycemic control during this transition.

Predictors of changing insulin dose requirements and glycaemic control in children, adolescents and young adults with Type 1 diabetes

AIMS

To investigate trajectories of daily insulin dose requirements and glycaemic control in children, adolescents and young adults with Type 1 diabetes and to identify factors associated with changing insulin needs and deterioration in HbA_1c .

METHODS

The sample was a dynamic cohort of 635 children, adolescents and young adults with Type 1 diabetes from one centre. Data from clinic visits occurring over 20 years (1993-2013) were extracted from medical records. From age 7-24 years, we evaluated HbA_1c and insulin dose according to sex, insulin regimen and weight status.

RESULTS

Participants provided a mean ± sd of 10.7±4.3 years of insulin dose data and 12.0±4.6 years of HbA_1c data. At first observation, the mean ± sd age was 10.0±2.6 years, diabetes duration was 2.8±2.1 years, insulin dose was 0.8±0.2 units/kg and HbA_1c was 74±18 mmol/mol (8.9±1.6%). Insulin dose was higher in girls at ages 8-13 years (P<0.0001 to P<0.01), but higher in boys/young men at ages 16-21 years (P<0.0001 to P=0.04). HbA_1c was higher in girls/young women at ages 16-24 years (P<0.0001 to P=0.01). Compared with injection therapy, pump therapy was associated with lower insulin dose at ages 8-24 years (P<0.0001 to P=0.03) and lower HbA_1c at ages 8-22 years (P<0.0001 to P=0.005). HbA_1c did not differ between overweight/obese and normal weight individuals, but overweight/obese individuals had higher insulin dose at ages 8-13 years (P<0.0001 to P=0.03).

CONCLUSIONS

This longitudinal assessment identifies clinically meaningful modifiable (e.g. insulin regimen) and non-modifiable (e.g. sex) factors predictive of insulin requirements and HbA_1c levels in young people with Type 1 diabetes; anticipatory insulin adjustments may improve glycaemic control.

Association of Race and Ethnicity With Glycemic Control and Hemoglobin A1c Levels in Youth With Type 1 Diabetes

IMPORTANCE

Health disparities in the clinical presentation and outcomes among youth with type 1 diabetes exist. Long-term glycemic control patterns in racially/ethnically diverse youth are not well described.

OBJECTIVES

To model common trajectories of hemoglobin A1c (HbA1c) among youth with type 1 diabetes and test how trajectory group membership varies by race/ethnicity.

DESIGN SETTING AND PARTICIPANTS

Longitudinal cohort study conducted in 5 US locations. The analysis included data from 1313 youths (aged <20 years) newly diagnosed in 2002 through 2005 with type 1 diabetes in the SEARCH for Diabetes in Youth study (mean [SD] age at diabetes onset, 8.9 [4.2] years) who had 3 or more HbA1c study measures during 6.1 to 13.3 years of follow-up. Data were analyzed in 2017.

EXPOSURES

Self-reported race/ethnicity.

MAIN OUTCOMES AND MEASURES

Hemoglobin A1c trajectories identified through group-based trajectory modeling over a mean (SD) of 9.0 (1.4) years of diabetes duration. Multinomial models studied the association of race/ethnicity with HbA1c trajectory group membership, adjusting for demographic characteristics, clinical factors, and socioeconomic position.

RESULTS

The final study sample of 1313 patients was 49.3% female (647 patients) with mean (SD) age 9.7 (4.3) years and mean (SD) disease duration of 9.2 (6.3) months at baseline. The racial/ethnic composition was 77.0% non-Hispanic white (1011 patients), 10.7% Hispanic (140 patients), 9.8% non-Hispanic black (128 patients), and 2.6% other race/ethnicity (34 patients). Three HbA1c trajectories were identified: group 1, low baseline and mild increases (50.7% [666 patients]); group 2, moderate baseline and moderate increases (41.7% [548 patients]); and group 3, moderate baseline and major increases (7.5% [99 patients]). Group 3 was composed of 47.5% nonwhite youths (47 patients). Non-Hispanic black youth had 7.98 higher unadjusted odds (95% CI, 4.42-14.38) than non-Hispanic white youth of being in the highest HbA1c trajectory group relative to the lowest HbA1c trajectory group; the association remained significant after full adjustment (adjusted odds ratio of non-Hispanic black race in group 3 vs group 1, 4.54; 95% CI, 2.08-9.89). Hispanic youth had 3.29 higher unadjusted odds (95% CI, 1.78-6.08) than non-Hispanic white youth of being in the highest HbA1c trajectory group relative to the lowest HbA1c trajectory group; the association remained significant after adjustment (adjusted odds ratio of Hispanic ethnicity in group 3 vs group 1, 2.24; 95% CI, 1.02-4.92). In stratified analyses, the adjusted odds of nonwhite membership in the highest HbA1c trajectory remained significant among male patients and youth diagnosed at age 9 years or younger, but not female patients and youth who were older than 9 years when they were diagnosed (P for interaction = .04 [sex] and .02 [age at diagnosis]).

CONCLUSIONS AND RELEVANCE

There are racial/ethnic differences in long-term glycemic control among youth with type 1 diabetes, particularly among nonwhite male patients and nonwhite youth diagnosed earlier in life.

Longitudinal trends in HbA1c patterns and association with outcomes: A systematic review

BACKGROUND

This study aimed to review studies that identified patterns of longitudinal HbA1c trends in patients with diabetes and to summarize factors and outcomes associated with distinct trajectory patterns.

METHODS

PubMed and Web of Science were systematically searched for studies examining HbA1c trends among patients with diabetes from database inception through September 2017. Articles were included if they met the following inclusion criteria: (a) longitudinal study of subjects with diabetes only, (b) use of serial measurements of HbA1c , and (c) analysis of the trend of HbA1c using group-based trajectory approaches.

RESULTS

Twenty studies were included, 11 on type 1 diabetes and 9 on type 2 diabetes. These studies identified 2 to 6 HbA1c trajectory patterns. The most commonly identified patterns included stable HbA1c around 7.0% and at levels between 8.0% and 9.9%, which usually captured the HbA1c pattern among the majority of subjects in the study population. Unstable patterns identified included increasing HbA1c trend, decreasing HbA1c trend, and non-linear patterns. These patterns were associated with differential risk of disease outcomes, over and beyond single-point HbA1c measures. Age, gender, ethnicity, diabetes duration, disease management frequency, cardiovascular risk factors, insulin treatment, family environment, and psychosocial factors were the most frequently reported factors associated with membership of specific HbA1c pattern groups.

CONCLUSION

Common patterns of longitudinal HbA1c trends were identified despite heterogeneity among the studies. A better understanding of what underlies these different patterns may provide opportunities to tailor therapies and care for these patients to reduce adverse outcomes.

Self- and Social-Regulation in Type 1 Diabetes Management During Late Adolescence and Emerging Adulthood

PURPOSE OF REVIEW

This paper aims to examine how self-regulation (i.e., cognition, emotion) and social-regulation (i.e., parents, friends, romantic partners) are interrelated risk and protective factors for type 1 diabetes management during late adolescence and emerging adulthood.

RECENT FINDINGS

Problems in cognitive (e.g., executive function) and emotional (e.g., depressive symptoms) self-regulation are associated with poorer management, both at the between- and within-person levels. Better management occurs when parents are supportive and when individuals actively regulate the involvement of others (e.g., seek help, minimize interference). Friends both help and hinder self-regulation, while research on romantic partners is limited. Facets of self- and social-regulation are important risk and protective factors for diabetes management during emerging adulthood. At this time when relationships are changing, the social context of diabetes may need to be regulated to support diabetes management. Interventions targeting those with self-regulation problems and facilitating self- and social-regulation in daily life may be useful.

Trajectories of Glycemic Change in a National Cohort of Adults With Previously Controlled Type 2 Diabetes

BACKGROUND

Individualized diabetes management would benefit from prospectively identifying well-controlled patients at risk of losing glycemic control.

OBJECTIVES

To identify patterns of hemoglobin A1c (HbA1c) change among patients with stable controlled diabetes.

RESEARCH DESIGN

Cohort study using OptumLabs Data Warehouse, 2001-2013. We develop and apply a machine learning framework that uses a Bayesian estimation of the mixture of generalized linear mixed effect models to discover glycemic trajectories, and a random forest feature contribution method to identify patient characteristics predictive of their future glycemic trajectories.

SUBJECTS

The study cohort consisted of 27,005 US adults with type 2 diabetes, age 18 years and older, and stable index HbA1c <7.0%.

MEASURES

HbA1c values during 24 months of observation.

RESULTS

We compared models with k=1, 2, 3, 4, 5 trajectories and baseline variables including patient age, sex, race/ethnicity, comorbidities, medications, and HbA1c. The k=3 model had the best fit, reflecting 3 distinct trajectories of glycemic change: (T1) rapidly deteriorating HbA1c among 302 (1.1%) youngest (mean, 55.2 y) patients with lowest mean baseline HbA1c, 6.05%; (T2) gradually deteriorating HbA1c among 902 (3.3%) patients (mean, 56.5 y) with highest mean baseline HbA1c, 6.53%; and (T3) stable glycemic control among 25,800 (95.5%) oldest (mean, 58.5 y) patients with mean baseline HbA1c 6.21%. After 24 months, HbA1c rose to 8.75% in T1 and 8.40% in T2, but remained stable at 6.56% in T3.

CONCLUSIONS

Patients with controlled type 2 diabetes follow 3 distinct trajectories of glycemic control. This novel application of advanced analytic methods can facilitate individualized and population diabetes care by proactively identifying high risk patients.

Impact of deprivation, ethnicity, and insulin pump therapy on developmental trajectories of diabetes control in COB type 1 diabetes

BACKGROUND

There is marked variation in diabetes outcomes for children and adolescents across the UK. We used modelling techniques to examine the independent contributions of deprivation, ethnicity, insulin pump use, and health service use on HbA_1c trajectories across adolescence.

METHODS

Prospective data from a large UK Paediatric & Adolescent Diabetes Service on subjects with type 1 diabetes (T1D) aged 9-17 years from January 2008 to December 2013: 2560 HbA_1c datapoints were available on 384 patients [193 (50.4%) female]. Sequential multilevel growth models assessed the effects of sex, duration of diabetes, deprivation, ethnicity, insulin pump use, and health service use on HbA_1c . Growth mixture models were used to identify discrete HbA_1c trajectories across adolescence.

RESULTS

Mean clinic HbA_1c decreased from 2008 to 2013 by 0.122% (95% confidence interval: 0.034, 0.210; P = .007) per year. The optimal multilevel growth model showed mean HbA_1c increased with age (B = 0.414, P < .0001), and that mean HbA_1c was predicted by white/British ethnicity (B = -0.748, P = .004), clinic visits (B = 0.041, P = .04), and pump use (B = -0.568, P < .0001) but not deprivation. The optimal mixture model was a four trajectory group solution, with 45.1% in Good Control, 39.6% with Deteriorating Control, 6.5% with Rapidly Deteriorating Control, and 8.8% in Poor Control across adolescence. Only pump use predicted trajectory group membership, being protective against membership of all other trajectories compared with Good Control.

CONCLUSIONS

Increasing uptake of insulin pumps and ensuring access to health services are likely to be the most effective means of reducing inequalities in outcomes of T1D in children and young people.

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

OBJECTIVE

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

RESEARCH DESIGN AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Effects of Triple P parenting intervention on child health outcomes for childhood asthma and eczema: Randomised controlled trial

Childhood chronic health conditions have considerable impact on children. We aimed to test the efficacy of a brief, group-based parenting intervention for improving illness-related child behaviour problems, parents' self-efficacy, quality of life, parents' competence with treatment, and symptom severity. A 2 (intervention vs. care as usual) by 3 (baseline, post-intervention, 6-month follow-up) design was used, with random group assignment. Participants were 107 parents of 2- to 10-year-old children with asthma and/or eczema. Parents completed self-report questionnaires, symptom diaries, and home observations were completed. The intervention comprised two 2-h group discussions based on Triple P. Parents in the intervention group reported (i) fewer eczema-related, but not asthma-related, child behaviour problems; (ii) improved self-efficacy for managing eczema, but not asthma; (iii) better quality of life for parent and family, but not child; (iv) no change in parental treatment competence; (v) reduced symptom severity, particularly for children prescribed corticosteroid-based treatments. Results demonstrate the potential for brief parenting interventions to improve childhood chronic illness management, child health outcomes, and family wellbeing. Effects were stronger for eczema-specific outcomes compared to asthma-specific outcomes. Effects on symptom severity are very promising, and further research examining effects on objective disease severity and treatment adherence is warranted.

AUSTRALIA NEW ZEALAND CLINICAL TRIALS REGISTRATION

ACTRN12611000558921.

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

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

Insulin pump use and glycemic control in adolescents with type 1 diabetes: Predictors of change in method of insulin delivery across two years

Few studies have explored durability of insulin pump use, and none have explored the link between depression and pump discontinuation. To examine the relationship between depressive symptoms [measured by the Children's Depression Inventory (CDI)], method of insulin delivery, and hemoglobin A1c (A1c), mixed models were used with data from 150 adolescents with type 1 diabetes (T1D) and visits every 6 months for 2 years. Of the 63% who used a pump, compared with multiple daily injections (MDI) at baseline, there were higher proportions who were non-minorities, had caregivers with a college degree, private insurance, and two caregivers in the home (p ≤ 0.01). After adjusting for time, sex, age, T1D duration, frequency of blood glucose monitoring, ethnicity, insurance, and caregiver number and education, baseline pump use was associated with -0.79% lower mean A1c [95% confidence interval (CI): -1.48, -0.096; p = 0.03]. For those using a pump at baseline, but switching to MDI during the study (n = 9), mean A1c was 1.38% higher (95% CI: 0.68, 2.08; p < 0.001) than that for those who did not switch method of delivery. A 10-point increase in CDI was associated with a 0.39% increase in A1c (95% CI: 0.16, 0.61; p = 0.001), independent of pump use. Regarding the temporal relationship between CDI score and changing method of insulin delivery, prior higher CDI score was associated with switching from pump to MDI (odds ratio = 1.21; 95% CI: 1.05, 1.39; p = 0.007). Clinicians should be aware of the associations between depressive symptoms, change in insulin delivery method, and the effect on glycemic control.

Assessing Insulin Delivery Device Satisfaction in Patients with Type 1 and Type 2 Diabetes

Over the past several decades, insulin treatment has changed drastically, not only with the development of further insulin analogs but also with the introduction of novel insulin delivery devices such as pumps and pens. In addition, adjunct devices such as continuous glucose monitors and sensor-augmented pumps have become increasingly used in clinical care, increasing the volume of information available to patients and providers. However, with the development of new devices it has become clear that along with the many benefits of these advances, the use of these devices can also present a burden to people with diabetes. For example, some patients report being overwhelmed by too much data when using continuous glucose monitors. Furthermore, there are concerns regarding the accuracy of some of these new devices, particularly for glucose monitoring. As a result, some patients may choose not to use available devices, despite the recognized benefits. Therefore, it is critical to understand how the various insulin delivery devices available currently and in the future affect patients in terms of their diabetes management and perceived burdens and to understand which patient characteristics may predict a lack of satisfaction with these devices. This critical gap in our knowledge is addressed in an article in this issue of the journal through the development of a questionnaire that allows for a better understanding of the impact of insulin delivery devices on quality of life and diabetes management among both type 1 diabetes and insulin-dependent type 2 diabetes patients. The novelty, as well as limitations, of this new instrument for the assessment of insulin delivery device satisfaction are discussed.

Predicting Health Resilience in Pediatric Type 1 Diabetes: A Test of the Resilience Model Framework

OBJECTIVES

This research examined whether individual and family-level factors during the transition from late childhood to early adolescence protected individuals from an increased risk of poor glycemic control across time, which is a predictor of future diabetes-related complications (i.e., health resilience).

METHODS

This longitudinal, multisite study included 239 patients with type 1 diabetes and their caregivers. Glycemic control was based on hemoglobin A1c. Individual and family-level factors included: demographic variables, youth behavioral regulation, adherence (frequency of blood glucose monitoring), diabetes self-management, level of parental support for diabetes autonomy, level of youth mastery and responsibility for diabetes management, and diabetes-related family conflict.

RESULTS

Longitudinal mixed-effects logistic regression indicated that testing blood glucose more frequently, better self-management, and less diabetes-related family conflict were indicators of health resilience.

CONCLUSIONS

Multiple individual and family-level factors predicted risk for future health complications. Future research should develop interventions targeting specific individual and family-level factors to sustain glycemic control within recommended targets, which reduces the risk of developing future health complications during the transition to adolescence and adulthood.

Systematic review and meta-analysis of psychological interventions to promote treatment adherence in children, adolescents, and young adults with chronic illness

OBJECTIVE

This meta-analysis examined the effectiveness of recent adherence-promoting interventions for youth with chronic health conditions.

METHODS

Peer-reviewed randomized controlled trials of adherence-promoting interventions for youth with a chronic illness published between 2007 and 2013 (n = 23) were reviewed. Intervention delivery (in-person vs. technology-based) and outcome measurement (e.g., self-report) were examined as potential moderators of treatment effects.

RESULTS

Mean effect sizes were small at posttreatment (d = 0.20, 95% confidence interval (CI): 0.08, 0.31, n = 23) and follow-up (d = 0.29, 95% CI: 0.15, 0.43, n = 9). Intervention delivery and outcome measurement did not account for variation in treatment effects (p > .05).

CONCLUSIONS

The small treatment effects of recent adherence-promoting intervention (APIs) reflect the methodological limitations of the included studies and the need to reexamine the delivery and mechanisms of adherence-promoting interventions.

A 3-year prospective study of parent-child communication in early adolescents with type 1 diabetes: relationship to adherence and glycemic control

OBJECTIVE

To examine changes in parent-child communication patterns and their relation to glycemic control and treatment adherence using observational data in a 3-year prospective multisite study of youth with type 1 diabetes aged 9-11 years at baseline and their families (n = 217).

METHODS

Adolescents and caregivers participated in a diabetes problem-solving discussion. Families were rated on negative and positive communication and interactions using the Interaction Behavior Code.

RESULTS

Maternal and paternal negative communication decreased over time, whereas adolescent and maternal positive communication and positive reciprocity increased. Baseline preadolescent youth and maternal positive communication predicted adherence 3 years later. Changes in family communication did not predict changes in glycemic control or adherence.

CONCLUSIONS

During the transition to adolescence, family communication changed in unexpected and positive ways. Additionally, the relationship of baseline family communication to subsequent adherence suggests the need to assess family communication concerning diabetes-related management during preadolescence.

Age at diagnosis predicts deterioration in glycaemic control among children and adolescents with type 1 diabetes

BACKGROUND

Poor glycemic control early in the course of type 1 diabetes mellitus (T1DM) increases the risk for microvascular complications. However, predictors of deteriorating control after diagnosis have not been described, making it difficult to identify high-risk patients and proactively provide aggressive interventions.

OBJECTIVE

We examined whether diagnostic age, gender, and race were associated with deteriorating glycemic control during the first 5 years after diagnosis.

PARTICIPANTS

2218 pediatric patients with T1DM.

METHODS

We conducted a longitudinal cohort study of pediatric patients with T1DM from the Midwest USA, 1993-2009, evaluating within-patient glycated hemoglobin (HbA1c) trajectories constructed from all available HbA1c values within 5 years of diagnosis.

RESULTS

52.6% of patients were male; 86.1% were non-Hispanic Caucasian. The mean diagnostic age was 9.0±4.1 years. The mean number of HbA1c values/year/participant was 2.4±0.9. HbA1c trajectories differed markedly across age groups, with older patients experiencing greater deterioration than their younger counterparts (p<0.001). HbA1c trajectories, stratified by age, varied markedly by race (p for race×diagnostic age <0.001). Non-Hispanic African-American patients experienced higher initial HbA1c (8.7% vs 7.6% (71.6 vs 59.6 mmol/mol); p<0.001), and greater deterioration in HbA1c than non-Hispanic Caucasian patients across diagnostic ages (rise of 2.04% vs 0.99% per year (22.3 vs 10.8 mmol/mol/year); p<0.0001).

CONCLUSIONS

Older diagnostic age and black race are major risk factors for deterioration in glycemic control early in the course of T1DM. These findings can inform efforts to explore the reasons behind these differences and develop preventive interventions for high-risk patients.