Time In Range in Children with Type 1 Diabetes Using Treatment Strategies Based on Nonautomated Insulin Delivery Systems in the Real World

Influence of Sex and Age on Irisin Levels in Pediatric Type 1 Diabetes: A Pilot Study

Background: Irisin is a myokine involved in the browning of adipocytes, the regulation of body composition and the enhancement of glycemic control. Additionally, irisin has been suggested to play a role in signaling mechanisms associated with the onset of puberty. In this study, we aimed to explore the interaction between muscle and adipose indices, urine irisin levels and glycemic control. Methods: This cross-sectional pilot study enrolled 76 consecutive pediatric patients (mean age 11.7 ± 3.8 years) diagnosed with type 1 diabetes (mean disease duration 2.1 ± 1.6 years). Body composition was assessed by bioelectrical impedance analysis (MFR z-score and skeletal muscle mass index). Urine irisin levels and glycemic control parameters (HbA1c, insulin dose-adjusted A1c [IDAA1c]) were evaluated. One linear regression model, stratified by sex, analyzed the sex-specific impact of puberty and age on irisin levels. A second linear regression model explored the associations of selected variables with irisin levels. Results: The first linear regression model revealed that irisin levels rise with age in prepubertal boys and decline with increased age among pubertal boys. The second linear regression analysis revealed no significant associations between irisin levels and metabolic parameters after adjusting for covariates. In contrast to boys, there were no significant interactions found in girls. Conclusions: Our novel findings revealed sex and age differences in the irisin levels of children and adolescents with type 1 diabetes. The dynamics underlying the role of irisin during pubertal development in the pediatric population with diabetes warrant further exploration.

A new glucose monitoring system for the intermittent monitoring of interstitial glucose values in patients with diabetes mellitus

Objectives

Glucose monitoring in diabetes is changing overtime with a constant development of new devices for continuous glucose monitoring (CGM). Aim of this observational, prospective study was to evaluate the clinical performance of a novel intermittently scanned CGM system, the Glunovo Flash in a cohort of patients with type 1 diabetes.

Methods

A total of 45 patients with T1D followed at the Endocrinology Unit of the ASST-FBF-Sacco (Milan) were enrolled. All patients were habitual CGM users and were asked to wear simultaneously the Glunovo Flash system and their habitual CGM device for 14 days. A comparison of CGM glucose metrics was performed. Patients' opinions on the new device were also collected.

Results

Thirty-five patients completed the study period of two weeks (7 habitual real time CGM users, 28 habitual intermittently scanned CGM users). Mean Time In Range resulted significantly higher with the novel studied sensor respect to intermittently scanned CGM comparator. No differences were found considering other glucose metrics. A positive correlation was found between the Time In Range recorded by Glunovo Flash and intermittently scanned CGM comparators as well as for Time Above Range, Glucose Management Indicator, Time Below Range and Coefficient of Variation. No correlations were found between glucose metrics recorded by Glunovo Flash and real time CGM comparators. Patients reported a positive experience of use with the new sensor but some elements appeared improvable.

Conclusions

The CGM device Glunovo Flash for patients with diabetes shows similar performance to other intermittently scanned CGM systems.

Beyond HbA1c: Identifying Gaps in Glycemic Control Among Children and Young People with Type 1 Diabetes Using Continuous Glucose Monitoring

OBJECTIVES

To describe continuous glucose monitoring (CGM) derived glycemic variables, and study their association with HbA1c and socio-economic factors in young people with Type 1 diabetes mellitus (T1DM).

METHODS

Ninety-two participants [age 15.7 ± 5.0 y (mean ± SD), HbA1c 8.0 ± 1.5% (mean ± SD)] wore a professional CGM sensor for 14 d.

RESULTS

Median (IQR) time in range (TIR) was 41 (18)%. Participants spent 41 ± 20% of their day in hyperglycemia (>180 mg/dl), and 14 (13)% in hypoglycemia (<70 mg/dl). High glycemic variability (percent CV >36%) was seen in 92% participants. Older age at diagnosis was associated with higher TIR (β = 0.267, p = 0.01), lower time above range (TAR) (β = -0.352, p <0.001), but higher time below range (TBR) (β = 0.274, p = 0.006). The use of NPH vs. glargine basal insulin was associated with higher TBR (β = -0.262, p = 0.009) but lower TAR (β = 0.202, p = 0.041). HbA1c showed negative correlation with TIR (r = -0.449, p <0.001) and TBR (r = -0.466, p <0.001) and positive correlation with TAR (r = 0.580, p <0.001) and mean glucose (r = 0.589, p <0.001).

CONCLUSIONS

These data demonstrate wide gaps between the recommended vs. real world glycemic variables in patients with T1DM in this region on multiple daily insulin injections. CGM identifies glycemic variability and complements HbA1c in improving glycemic control.

Clinical significance of coefficient of variation in continuous glucose monitoring for glycemic management in children and adolescents with type 1 diabetes

AIMS/INTRODUCTION

Coefficient of variation (CV) is an indicator for glucose variability in continuous glucose monitoring (CGM), and the target threshold of %CV in type 1 diabetes is proposed to be ≤36%. This study aimed to evaluate the clinical significance of CV in children and adolescents with type 1 diabetes.

MATERIALS AND METHODS

Participants included 66 children with type 1 diabetes. A total of 48 participants were treated with multiple daily injections of insulin, and 18 with continues subcutaneous insulin infusion, using intermittently scanned CGM. The frequencies of the CGM metrics and glycosylated hemoglobin values were examined, and the significance of a threshold %CV of 36% was evaluated.

RESULTS

The mean frequencies in time in range (TIR), time below range, %CV and the mean glycosylated hemoglobin value were 59.3 ± 16.1, 4.0 ± 3.5, 39.3 ± 6.2 and 7.3 ± 0.8%, respectively. The frequencies of participants who achieved a TIR >70% and a %CV of ≤36% were 24.1 and 27.3%, respectively. A total of 18 participants with a %CV of ≤36% had significantly higher TIR, lower time below range and lower glycosylated hemoglobin than the 48 with a %CV of >36% (72.6 ± 12.6 vs 52.4 ± 13.6, 2.4 ± 1.9 vs 4.6 ± 3.6, 6.9 ± 0.8 vs 7.4 ± 0.7%, respectively).

CONCLUSIONS

Children and adolescents with type 1 diabetes using intermittently scanned CGM had difficulties in achieving the recommended targets of TIR and CV. However, the target %CV of ≤36% seems to be an appropriate indicator for assessing glycemic control and risk of hypoglycemia in pediatric patients with type 1 diabetes with any treatment.

Satisfaction with continuous glucose monitoring is associated with quality of life in young people with type 1 diabetes regardless of metabolic control and treatment type

AIMS

While continuous glucose monitoring (CGM) and associated technologies have positive effects on metabolic control in young people with type 1 diabetes (T1D), less is known about their impact on quality of life (QoL). Here, we quantified CGM satisfaction and QoL in young people with T1D and their parents/caregivers to establish (i) the relationship between QoL and CGM satisfaction and (ii) the impact of the treatment regimen on QoL.

METHODS

This was a cross-sectional study of children and adolescents with T1D on different treatment regimens (multiple daily injections, sensor-augmented pumps and automated insulin delivery). QoL was assessed with the KINDL instrument, and CGM satisfaction with the CGM-SAT questionnaire was evaluated in both youths with T1D and their parents.

RESULTS

Two hundred and ten consecutively enrolled youths with T1D completed the KINDL and CGM-SAT questionnaires. The mean total KINDL score was greater than neutral in both subjects with T1D (3.99 ± 0.47) and parents (4.06 ± 0.40), and lower overall CGM-SAT scores (i.e., higher satisfaction) were significantly associated with higher QoL in all six KINDL subscales (p < 0.05). There were no differences in KINDL scores according to delivery technology or when participants were grouped according to optimal and sub-optimal glucose control.

CONCLUSIONS

Higher satisfaction with recent CGMs was associated with better QoL in all dimensions. QoL was independent of both the insulin delivery technology and glycaemic control. CGM must be further disseminated. Attention on perceived satisfaction with CGM should be incorporated with the clinical practice to improve the well-being of children and adolescents with T1D and their families.

Glucometrics and device satisfaction in children and adolescents with type 1 diabetes using different treatment modalities: A multicenter real-world observational study

AIMS

To analyze metabolic outcomes, diabetes impact and device satisfaction in children and adolescents with type 1 diabetes in Italy who used different treatment modalities for diabetes care in a real-life context.

METHODS

In this multicenter, nationwide, cross-sectional study, 1464 participants were enrolled at a routine visit. The following treatment modalities were considered MDI + SMBG; MDI + CGM; Sensor Augmented Pump Therapy; predictive management of low glucose; Hybrid Closed Loop (HCL); Advanced Hybrid Closed Loop (AHCL). Health related quality of life was evaluated by the Italian version of the Diabetes Impact and Device Satisfaction Scale (DIDS) questionnaire.

RESULTS

Patients treated with AID systems were more likely to have HbA1c ≤ 6.5 %, higher percentage of time with glucose levels between 70 and 180 mg/dL, lower percentage of time with glucose levels above 180 mg/dL, higher device satisfaction, and reduced impact of diabetes. All the therapeutic modalities with respect to MDI + CGM, except for MDI + SMBG, contributed to increase the device satisfaction. HCL and AHCL respect to MDI + CGM were associated with lower diabetes impact.

CONCLUSION

Real-life use of automated insulin delivery systems is associated with reduced type 1 diabetes impact, increased device satisfaction, and achievement of glycemic goals.

Aiming for the Best Glycemic Control Beyond Time in Range: Time in Tight Range as a New Continuous Glucose Monitoring Metric in Children and Adolescents with Type 1 Diabetes Using Different Treatment Modalities

Introduction: To evaluate time in tight range (TITR) 70-140 mg/dL (3.9-7.8 mmol/L), its correlation with standard continuous glucose monitoring (CGM) metrics and the clinical variables that possibly have a substantial impact on its value, in a large cohort of pediatric subjects using different treatment strategies. Materials and Methods: A total of 854 children and adolescents with type 1 diabetes were consecutively recruited in this real world, dual center, cross-sectional study. Participants were categorized into four treatment groups (multiple daily injections [MDI] + real-time CGM, MDI + intermittently scanned CGM, sensor augmented pump, and hybrid closed loop [HCL]). Demographical and clinical data, including CGM data, were collected and analyzed. Results: The overall study population exhibited an average TITR of 36.4% ± 12.8%. HCL users showed higher TITR levels compared to the other treatment groups (P < 0.001). A time in range (TIR) cut-off value of 71.9% identified subjects achieving a TITR ≥50% (area under curve [AUC] 0.98; 95% confidence interval 0.97-0.99, P < 0.001), and a strong positive correlation between these two metrics was observed (r = 0.95, P < 0.001). An increase in TIR of 1% was associated with 1.84 (R2 Nagelkerke = 0.35, P < 0.001) increased likelihood of achieving TITR ≥50%. Use of HCL systems (B = 7.78; P < 0.001), disease duration (B = -0.26, P = 0.006), coefficient of variation (B = -0.30, P = 0.004), and glycated hemoglobin (B = -8.82; P < 0.001) emerged as significant predictors of TITR levels. Conclusions: Our study highlights that most children and adolescents with type 1 diabetes present TITR levels below 50%, except those using HCL. Tailored interventions and strategies should be implemented to increase TITR.

Updating Our Understanding of Device Use in Adolescents: Demographic Factors and Preferences in a Group of Adolescents With Type 1 Diabetes

PURPOSE

The purpose of the study was to identify demographic factors associated with continuous glucose monitor (CGM) and automated insulin delivery (AID) use among adolescents with type 1 diabetes and to explore why adolescents may start and stop using CGMs.

METHODS

Adolescents ages 13 to 17 and caregivers completed demographic and device use surveys at baseline for a randomized trial of a behavioral intervention conducted at 2 large medical centers in the United States. This study is a secondary analysis of the demographic and device use data.

RESULTS

The study sample consisted of 198 participants ages 13 to 17, 58% female, 57% non-Hispanic White, 24% non-Hispanic Black, 19% other race and ethnicity. Eighty-one percent of adolescents were using CGM, and 10% reported past use. Forty percent of adolescents reported taking CGM breaks ranging hours to weeks. Higher CGM use was found in higher income families (>$90 000). No difference in CGM use was observed related to race or ethnicity.

CONCLUSIONS

These findings suggest CGM use is increasing even among adolescents, a group that historically has had the lowest device use. However, adolescents often take CGM breaks, and it is not clear if they adjust their diabetes management during these times. It is important for providers to understand when and why patients may take CGM breaks so education about diabetes management while off CGM can occur. Further investigation into management during CGM breaks, particularly in those using an AID system, is needed.

Satisfaction with continuous glucose monitoring is positively correlated with time in range in children with type 1 diabetes

AIMS

Continuous glucose monitoring (CGM) can improve glucometrics in children with type 1 diabetes (T1D), and its efficacy is positively related to glucose sensor use for at least 60% of the time. We therefore investigated the relationship between CGM satisfaction as assessed by a robust questionnaire and glucose control in pediatric T1D patients.

METHODS

This was a cross-sectional study of children and adolescents with T1D using CGM. The CGM Satisfaction (CGM-SAT) questionnaire was administered to patients and demographic, clinical, and glucometrics data were recorded.

RESULTS

Two hundred and ten consecutively enrolled patients attending 14 Italian pediatric diabetes clinics completed the CGM-SAT questionnaire. CGM-SAT scores were not associated with age, gender, annual HbA1c, % of time with an active sensor, time above range (TAR), time below range (TBR), and coefficient of variation (CV). However, CGM satisfaction was positively correlated with time in range (TIR, p < 0.05) and negatively correlated with glycemia risk index (GRI, p < 0.05).

CONCLUSIONS

CGM seems to have a positive effect on glucose control in patients with T1D. CGM satisfaction is therefore an important patient-reported outcome to assess and it is associated with increased TIR and reduced GRI.

To Use or Not to Use a Self-monitoring of Blood Glucose System? Real-world Flash Glucose Monitoring Patterns Using a Cluster Analysis of the FGM-Japan Study

Objective This study investigated self-monitoring of blood glucose (SMBG) adherence and flash glucose monitoring patterns using a cluster analysis in Japanese type 1 diabetes (T1D) patients with intermittently scanned continuous glucose monitoring (isCGM). Methods We measured SMBG adherence and performed a data-driven cluster analysis using a hierarchical clustering in T1D patients from Japan using the FreeStyle Libre system. Clusters were based on three variables (testing glucose frequency and referred Libre data for hyperglycemia or hypoglycemia). Patients We enrolled 209 participants. Inclusion criteria were patients with T1D, duration of isCGM use ≥3 months, age ≥20 years old, and regular attendance at the collaborating center. Results The rate of good adherence to SMBG recommended by a doctor was 85.0%. We identified three clusters: cluster 1 (low SMBG test frequency but high reference to Libre data, 17.7%), cluster 2 (high SMBG test frequency but low reference to Libre data, 34.0%), and cluster 3 (high SMBG test frequency and high reference to Libra data, 48.3%). Compared with other clusters, individuals in cluster 1 were younger, those in cluster 2 had a shorter Libre duration, and individuals in cluster 3 had lower time-in-range, higher severe diabetic distress, and high intake of snacks and sweetened beverages. There were no marked differences in the incidence of diabetic complications and rate of wearing the Libre sensor among the clusters. Conclusion We stratified the patients into three subgroups with varied clinical characteristics and CGM metrics. This new substratification might help tailor diabetes management of patients with T1D using isCGM.

Pediatric Type 1 Diabetes: Mechanisms and Impact of Technologies on Comorbidities and Life Expectancy

Type 1 diabetes (T1D) is one of the most common chronic diseases in childhood, with a progressively increasing incidence. T1D management requires lifelong insulin treatment and ongoing health care support. The main goal of treatment is to maintain blood glucose levels as close to the physiological range as possible, particularly to avoid blood glucose fluctuations, which have been linked to morbidity and mortality in patients with T1D. Indeed, the guidelines of the International Society for Pediatric and Adolescent Diabetes (ISPAD) recommend a glycated hemoglobin (HbA1c) level < 53 mmol/mol (<7.0%) for young people with T1D to avoid comorbidities. Moreover, diabetic disease strongly influences the quality of life of young patients who must undergo continuous monitoring of glycemic values and the administration of subcutaneous insulin. In recent decades, the development of automated insulin delivery (AID) systems improved the metabolic control and the quality of life of T1D patients. Continuous subcutaneous insulin infusion (CSII) combined with continuous glucose monitoring (CGM) devices connected to smartphones represent a good therapeutic option, especially in young children. In this literature review, we revised the mechanisms of the currently available technologies for T1D in pediatric age and explored their effect on short- and long-term diabetes-related comorbidities, quality of life, and life expectation.

Measures of Patient-Reported Expectations, Acceptance, and Satisfaction Using Automated Insulin Delivery Systems: A Review

In people with type 1 diabetes, Automated Insulin Delivery (AID) systems adjust insulin delivery in response to sensor glucose data and consist of three components: an insulin pump, a continuous glucose sensor, and an algorithm that determines insulin delivery. To date, all the available AID systems require users to announce carbohydrate intake and deliver meal boluses, as well as respond to system alarms. The use of AID devices both initially and over time may be influenced by a variety of psychological factors. Analysis of patient-related outcomes should be taken into account, while recruiting applicants for the systems who are motivated and have realistic expectations in order to prevent AID dropout. We report an up-to-date summary of the available measures and semi-structured interview content to assess AID expectations, acceptance, and satisfaction using the AID systems. In conclusion, we suggest, before and after starting using AID systems, performing a specific evaluation of the related psychological implications, using validated measures and semi-structured interviews, that allows diabetes care providers to tailor their education approach to the factors that concern the patient at that time; they can teach problem-solving skills and other behavioral strategies to support sustained use of the AID system.

Glycemia Risk Index as a novel metric to evaluate the safety of glycemic control in children and adolescents with Type 1 Diabetes: an observational, multicenter, real-life cohort study

Glycemia Risk Index (GRI) is a novel composite metric for the evaluation of the safety of glycemic management and control. The aim of this study was to evaluate GRI and its correlations with continuous glucose monitoring (CGM) metrics by analysing real-life CGM data in 1067 children/adolescents with type 1 Diabetes (T1D) using four different treatment strategies (intermittently scanned CGM [isCGM]-Multiple daily injections [MDI]; real time CGM [rtCGM]-MDI; rt-CGM-insulin pump [IP]; Hybrid Closed-Loop [HCL] therapy). GRI was positively correlated with High Blood Glucose Index (HBGI), Low Blood Glucose Index (LBGI), mean glycemia, its standard deviation, coefficient of variation and HbA1c. The four treatment strategies groups showed significantly different GRI with the lowest value in the HCL group (30.8) and the highest in the isCGM-MDI group (68.4). These findings support the use of GRI for the assessment of the glycemic risk and the safety of specific treatment in paediatric subjects with T1D.

Glycemic Control by Treatment Modalities: National Registry-Based Population Data in Children and Adolescents with Type 1 Diabetes

INTRODUCTION

The aim of the study was to assess the differences in key parameters of type 1 diabetes (T1D) control associated with treatment and monitoring modalities including newly introduced hybrid closed-loop (HCL) algorithm in children and adolescents with T1D (CwD) using the data from the population-wide pediatric diabetes registry ČENDA.

METHODS

CwD younger than 19 years with T1D duration >1 year were included and divided according to the treatment modality and type of CGM used: multiple daily injection (MDI), insulin pump without (CSII) and with HCL function, intermittently scanned continuous glucose monitoring (isCGM), real-time CGM (rtCGM), and intermittent or no CGM (noCGM). HbA1c, times in glycemic ranges, and glucose risk index (GRI) were compared between the groups.

RESULTS

Data of a total of 3,251 children (mean age 13.4 ± 3.8 years) were analyzed. 2,187 (67.3%) were treated with MDI, 1,064 (32.7%) with insulin pump, 585/1,064 (55%) with HCL. The HCL users achieved the highest median TIR 75.4% (IQR 6.3) and lowest GRI 29.1 (7.8), both p < 0.001 compared to other groups, followed by MDI rtCGM and CSII groups with TIR 68.8% (IQR 9.0) and 69.0% (7.5), GRI 38.8 (12.5) and 40.1 (8.5), respectively (nonsignificant to each other). These three groups did not significantly differ in their HbA1c medians (51.8 [IQR 4.5], 50.7 [4.5], and 52.7 [5.7] mmol/mol, respectively). NoCGM groups had the highest HbA1c and GRI and lowest TIR regardless of the treatment modality.

CONCLUSION

This population-based study shows that the HCL technology is superior to other treatment modalities in CGM-derived parameters and should be considered as a treatment of choice in all CwD fulfilling the indication criteria.

Automated Insulin Delivery (AID) Systems: Use and Efficacy in Children and Adults with Type 1 Diabetes and Other Forms of Diabetes in Europe in Early 2023

Type 1 diabetes (T1D) patients' lifestyle and prognosis has remarkably changed over the years, especially after the introduction of insulin pumps, in particular advanced hybrid closed loop systems (AHCL). Emerging data in literature continuously confirm the improvement of glycemic control thanks to the technological evolution taking place in this disease. As stated in previous literature, T1D patients are seen to be more satisfied thanks to the use of these devices that ameliorate not only their health but their daily life routine as well. Limited findings regarding the use of new devices in different age groups and types of patients is their major limit. This review aims to highlight the main characteristics of each Automated Insulin Delivery (AID) system available for patients affected by Type 1 Diabetes Mellitus. Our main goal was to particularly focus on these systems' efficacy and use in different age groups and populations (i.e., children, pregnant women). Recent studies are emerging that demonstrate their efficacy and safety in younger patients and other forms of diabetes.

Comparisons of school-day glycemia in different settings for children with type 1 diabetes using continuous glucose monitoring

Objective

Using continuous glucose monitoring (CGM), we examined patterns in glycemia during school hours for children with type 1 diabetes, exploring differences between school and non-school time.

Methods

We conducted a retrospective analysis of CGM metrics in children 7-12 years (n=217, diabetes duration 3.5±2.5 years, hemoglobin A1c 7.5±0.8%). Metrics were obtained for weekday school hours (8 AM to 3 PM) during four weeks in fall 2019. Two comparison settings included weekend (fall 2019) and weekday (spring 2020) data when children had transitioned to virtual school due to COVID-19. We used multilevel mixed models to examine factors associated with time in range (TIR) and compare glycemia between in-school, weekends, and virtual school.

Results

Though CGM metrics were clinically similar across settings, TIR was statistically higher, and time above range (TAR), mean glucose, and standard deviation (SD) lower, for weekends and virtual school (p<0.001). Hour and setting exhibited a significant interaction for several metrics (p<0.001). TIR in-school improved from a mean of 40.9% at the start of the school day to 58.0% later in school, with a corresponding decrease in TAR. TIR decreased on weekends (60.8 to 50.7%) and virtual school (62.2 to 47.8%) during the same interval. Mean glucose exhibited a similar pattern, though there was little change in SD. Younger age (p=0.006), lower hemoglobin A1c (p<0.001), and insulin pump use (p=0.02) were associated with higher TIR in-school.

Conclusion

Although TIR was higher for weekends and virtual school, glycemic metrics improve while in-school, possibly related to beneficial school day routines.

Association of Achieving Time in Range Clinical Targets With Treatment Modality Among Youths With Type 1 Diabetes

IMPORTANCE

Continuous glucose monitoring (CGM) devices have demonstrated efficacy in adults and more recently in youths and older adults with type 1 diabetes. In adults with type 1 diabetes, the use of real-time CGM compared with intermittently scanned CGM was associated with improved glycemic control, but there are limited data available for youths.

OBJECTIVE

To assess real-world data on achievement of time in range clinical targets associated with different treatment modalities in youths with type 1 diabetes.

DESIGN, SETTING, AND PARTICIPANTS

This multinational cohort study included children, adolescents, and young adults younger than 21 years (hereinafter referred to collectively as youths) with type 1 diabetes for a duration of at least 6 months who provided CGM data between January 1, 2016, and December 31, 2021. Participants were enrolled from the international Better Control in Pediatric and Adolescent Diabetes: Working to Create Centers of Reference (SWEET) registry. Data from 21 countries were included. Participants were divided into 4 treatment modalities: intermittently scanned CGM with or without insulin pump use and real-time CGM with or without insulin pump use.

EXPOSURES

Type 1 diabetes and the use of CGM with or without an insulin pump.

MAIN OUTCOMES AND MEASURES

Proportion of individuals in each treatment modality group achieving recommended CGM clinical targets.

RESULTS

Among the 5219 participants (2714 [52.0%] male; median age, 14.4 [IQR, 11.2-17.1] years), median duration of diabetes was 5.2 (IQR, 2.7-8.7) years and median hemoglobin A1c level was 7.4% (IQR, 6.8%-8.0%). Treatment modality was associated with the proportion of individuals achieving recommended clinical targets. Adjusted for sex, age, diabetes duration, and body mass index standard deviation score, the proportion achieving the recommended greater than 70% time in range target was highest with real-time CGM plus insulin pump use (36.2% [95% CI, 33.9%-38.4%]), followed by real-time CGM plus injection use (20.9% [95% CI, 18.0%-24.1%]), intermittently scanned CGM plus injection use (12.5% [95% CI, 10.7%-14.4%]), and intermittently scanned CGM plus insulin pump use (11.3% [95% CI, 9.2%-13.8%]) (P < .001). Similar trends were observed for less than 25% time above (real-time CGM plus insulin pump, 32.5% [95% CI, 30.4%-34.7%]; intermittently scanned CGM plus insulin pump, 12.8% [95% CI, 10.6%-15.4%]; P < .001) and less than 4% time below range target (real-time CGM plus insulin pump, 73.1% [95% CI, 71.1%-75.0%]; intermittently scanned CGM plus insulin pump, 47.6% [95% CI, 44.1%-51.1%]; P < .001). Adjusted time in range was highest among real-time CGM plus insulin pump users (64.7% [95% CI, 62.6%-66.7%]). Treatment modality was associated with the proportion of participants experiencing severe hypoglycemia and diabetic ketoacidosis events.

CONCLUSIONS AND RELEVANCE

In this multinational cohort study of youths with type 1 diabetes, concurrent use of real-time CGM and an insulin pump was associated with increased probability of achieving recommended clinical targets and time in range target as well as lower probability of severe adverse events compared with other treatment modalities.

One-year follow-up comparison of two hybrid closed-loop systems in Italian children and adults with type 1 diabetes

BACKGROUND AND AIMS

Tandem Control-IQ and MiniMed 780G are the main Advanced Hybrid Closed Loop (AHCL) systems currently available in pediatric and adult patients with Type 1 Diabetes (T1D). The aim of our study was to evaluate glycemic control after 1-year of follow-up extending our previous study of 1-month comparison between the two systems.

METHODS

We retrospectively compared clinical and continuous glucose monitoring (CGM) data from the patients included in the previous study which have completed 1-year observation period. The study population consisted of 74 patients, 42 Minimed 780G users and 32 Tandem Control-IQ users. Linear mixed models with random intercept were performed to study the variations over time and the interaction between time and system; Mann-Whitney or T-test were used to compare systems at 1-year.

RESULTS

Both systems have been shown to be effective in maintaining the glycemic improvement achieved one month after starting AHCL. Significant changes over time were observed for TIR, TAR, TAR>250mg/dl, average glucose levels and SD (p<0.001). At 1-year follow-up Minimed 780G obtained better improvement in TIR (p<0.001), TAR (p=0.002), TAR>250mg/dl (p=0.001), average glucose levels (p<0.001). The comparison of the glycemic parameters at 1-year showed a significant superiority of Minimed 780G in terms of TIR (71% vs 68%; p=0.001), TAR (p=0.001), TAR>250 (p=0.009), average glucose levels(p=0.001) and SD (p=0.031).

CONCLUSIONS

The use of AHCL systems led to a significant improvement of glycemic control at 1-month, which is maintained at 1-year follow-up. MiniMed is more effective than Tandem in reaching the International recommended glycemic targets. Continuous training and education in the use of technology is essential to get the best out of the most advanced technological tools.

Significance of the CGM metric of time in range in children and adolescents with type 1 diabetes

Continuous glucose monitoring (CGM) has been widely used in children and adolescents as well as adults with type 1 diabetes. CGM metrics include three key measurements of target glucose: time in range (TIR: 70-180 mg/dL), time below range (TBR: <70 mg/dL), and time above range (TAR: >180 mg/dL). The primary goal of optimal glycemic control is to increase TIR to more than 70%, while simultaneously reducing TBR to less than 4%, while minimizing severe hypoglycemia to less than 1%, as proposed by the Advanced Technologies and Treatments for Diabetes (ATTD) panel. However, several studies have indicated that the TIR goal is quite difficult to achieve in pediatric patients who have remarkable interindividual and day-to-day glycemic variation due to their irregular lifestyles. Previous studies have demonstrated that patients without an automated insulin delivery system are unlikely to attain the recommended glycemic goals. On the other hand, reduction of hypoglycemia, particularly minimizing severe hypoglycemia, is a critical issue in the effective management of children with type 1 diabetes. Frequent episodes of severe hypoglycemia and hypoglycemia can cause lasting neurological damage. Accordingly, we propose reducing the TBR to less than 5%, rather than just targeting the TIR to more than 70%. In CGM metrics this should be the cardinal glycemic goal for pediatric patients who are either being treated with multiple daily injections of insulin or a conventional insulin pump, but who are not using an automated insulin delivery system.

Time With Glucose Level in Target Range Among Children and Adolescents With Type 1 Diabetes After a Software Update to a Closed-Loop Glucose Control System

This cohort study analyzes changes to the time with glucose level in target range among children and adolescents with type 1 diabetes after a software update to a closed-loop glucose control system.

Comparison of MiniMed 780G system performance in users aged younger and older than 15 years: Evidence from 12 870 real-world users

AIM

To investigate real-world glycaemic outcomes and goals achieved by users of the MiniMed 780G advanced hybrid closed loop (AHCL) system aged younger and older than 15 years with type 1 diabetes (T1D).

MATERIALS AND METHODS

Data uploaded by MiniMed 780G system users from 27 August 2020 to 22 July 2021 were aggregated and retrospectively analysed based on self-reported age (≤15 years and >15 years) for three cohorts: (a) post-AHCL initiation, (b) 6-month longitudinal post-AHCL initiation and (c) pre- versus post-AHCL initiation. Analyses included mean percentage of time spent in AHCL and at sensor glucose ranges, insulin delivered and the proportion of users achieving recommended glucose management indicator (GMI < 7.0%) and time in target range (TIR 70-180 mg/dl > 70%) goals.

RESULTS

Users aged 15 years or younger (N = 3211) achieved a GMI of 6.8% ± 0.3% and TIR of 73.9% ± 8.7%, while spending 92.7% of time in AHCL. Users aged older than 15 years (N = 8874) achieved a GMI of 6.8% ± 0.4% and TIR of 76.5% ± 9.4% with 92.3% of time in AHCL. Time spent at less than 70 mg/dl was within the recommended target of less than 4% (3.2% and 2.3%, respectively). Similar outcomes were observed for each group (N = 790 and N = 1642, respectively) in the first month following AHCL initiation, and were sustained over the 6-month observation period.

CONCLUSIONS

This real-world analysis shows that more than 75% of users with T1D aged 15 years or younger using the MiniMed 780G system achieved international consensus-recommended glycaemic control, mirroring the achievements of the population aged older than 15 years.

Comparison of two advanced hybrid closed loop in a pediatric population with type 1 diabetes: a real-life observational study

OBJECTIVE

The Advanced Hybrid Closed Loop (AHCL) systems have provided the potential to ameliorate glucose control in children with Type 1 Diabetes. The aim of the present work was to compare metabolic control obtained with 2 AHCL systems (Medtronic 780G system and Tandem Control IQ system) in a pediatric real-life clinical context.

RESEARCH DESIGN AND METHODS

It is an observational, real-life, monocentric study; thirty one children and adolescents (M:F = 15:16, age range 7.6-18 years, mean age 13.05 ± 2.4 years, Diabetes duration > 1 year) with T1D, previously treated with Predictive Low Glucose Suspend (PLGS) systems and then upgraded to AHCL have been enrolled. CGM data of the last four weeks of "PLGS system" (PRE period) with the first four weeks of AHCL system (POST period) have been compared.

RESULTS

For both AHCL systems, Medtronic 780G and Tandem Control IQ, respectively TIR at 4 weeks significantly increased, from 65.7 to 70.5% (p < 0.01) and from 64.8 to 70.1% (p < 0.01). (p < 0.01). The comparison between CGM metrics of the 2 evaluated systems doesn't show difference at baseline (last four weeks of PLGS system) and after four weeks of AHCL use.

CONCLUSIONS

To our knowledge, this study is the first real-life one comparing 2 AHCL systems in a pediatric population with T1D. It shows an improvement in glucose control when upgrading to AHCL. The comparison between the two AHCL systems did not show significant differences in the analyzed CGM metrics, meaning that the algorithms currently available are equally effective in promoting glucose control.

Current Status and Emerging Options for Automated Insulin Delivery Systems

Combining technologies including rapid insulin analogs, insulin pumps, continuous glucose monitors, and control algorithms has allowed for the creation of automated insulin delivery (AID) systems. These systems have proven to be the most effective technology for optimizing metabolic control and could hold the key to broadly achieving goal-level glycemic control for people with type 1 diabetes. The use of AID has exploded in the past several years with several options available in the United States and even more in Europe. In this article, we review the largest studies involving these AID systems, and then examine future directions for AID with an emphasis on usability.

Cost-Effectiveness Analysis of an Advanced Hybrid Closed-Loop Insulin Delivery System in People with Type 1 Diabetes in Greece

AbstractIntroduction: Usage of automated insulin delivery systems is increasing for the treatment of people with type 1 diabetes (T1D). This study compared long-term cost-effectiveness of the Advanced Hybrid Closed Loop MiniMed 780G (AHCL) system versus sensor augmented pump (SAP) system with predictive low glucose management (PLGM) or multiple daily injections (MDI) plus intermittently scanned continuous glucose monitoring (isCGM) in people with T1D in Greece. Methods: Analyses were performed using the IQVIA CORE Diabetes Model, with clinical input data sourced from various studies. In the AHCL versus SAP plus PLGM analysis, patients were assumed to have 7.5% baseline glycated hemoglobin (HbA1c), when comparing AHCL with MDI plus isCGM baseline HbA1c was assumed to be 7.8%. HbA1c was reduced to 7.0% following AHCL treatment initiation but remained at baseline levels in the comparator arms. Analyses were performed from a societal perspective over a lifetime time horizon. Future costs and clinical outcomes were discounted at 1.5% per annum. Results: AHCL was associated with increased quality-adjusted life expectancy of 0.284 quality-adjusted life years (QALYs) and EUR 10,173 lower mean total lifetime costs with SAP plus PLGM. Compared with MDI plus isCGM, AHCL was associated with increased quality-adjusted life expectancy of 2.708 QALYs, EUR 76,396 higher mean total lifetime costs, and an incremental cost-effectiveness ratio of EUR 29,869 per QALY. Extensive sensitivity analysis confirmed the robustness of results. Conclusions: Over patient lifetime, the MiniMed 780G system is likely to be cost saving compared with the SAP plus PLGM system and cost-effective compared with MDI plus isCGM in people with T1D in Greece.

High Glycemic Variability Is Associated with Worse Continuous Glucose Monitoring Metrics in Children and Adolescents with Type 1 Diabetes

OBJECTIVE

The primary aim of this study was to quantify the prevalence of children and adolescents with type 1 diabetes (T1D) who achieve the recommended target for coefficient of variation (CV) identifying the determining factors to reach this target. The secondary aim was to examine the relationship between CV, the other metrics derived from continuous glucose monitoring (CGM) data and clinical parameters.

METHOD

CGM data were collected from 805 children/adolescents with T1D. Several CGM metrics and patients' characteristics were evaluated. Participants were stratified by CV ≤36% and CV >36%. Binary logistic regression analysis was run to identify the determining factors of high CV.

RESULTS

CV was positively correlated with %TBR <70 mg/dL, %TBR <54 mg/dL, %TAR >250 mg/dL, low blood glucose index, and high blood glucose index and negatively with %TIR. CV ≤36% was found in 31.4% of the subjects. The CV >36% group spent less time in %TIR, more time in hypoglycemia and hyperglycemia with lower proportion of subjects using real-time CGM and continuous subcutaneous insulin infusion. Percentage of TBR <70 mg/dL and TAR >250 mg/dL were significant predictors of CV >36%, whereas age, gender, BMI, duration of diabetes, type of CGM device, type of insulin therapy administration and %TIR were not significant predictors (p < 0.001, R2 Nagelkerke = 0.48).

CONCLUSIONS

CV identifies children and adolescents with worse glycemic control at higher risk of both hypoglycemia and hyperglycemia.

Real-World Use of Continuous Glucose Monitoring (CGM) Systems Among Adolescents and Young Adults With Type 1 Diabetes: Reduced Burden, but Little Interest in Data Analysis

BACKGROUND

Since 2016, German health insurance companies reimburse continuous glucose monitoring (CGM) systems for persons with insulin-dependent diabetes, leading to a tremendous increase of CGM use. This study assessed the use of CGM, the satisfaction with, and the data analysis behavior among young people.

METHODS

During a diabetes camp for young people from all over Germany, participants anonymously answered a questionnaire on their method of glucose monitoring, satisfaction and quality of CGM use, HbA1c, and diabetes distress (Problem Areas in Diabetes Scale [PAID]-5).

RESULTS

A total of 308 participants (age 21.4 ± 3.5 years; 73% female; diabetes duration 10.1 ± 5.9 years) completed the questionnaire. Approximately, 25% used self-monitoring of blood glucose (SMBG), 46% intermittent-scanning continuous glucose monitoring (iscCGM), and 30% real-time continuous glucose monitoring (rtCGM). Mean HbA1c was slightly, but not significantly, higher among SMBG users compared with CGM users (8.0% ± 1.9% vs. 7.7% ± 1.4%; P = .791). Diabetes distress was not associated with the method of glucose monitoring (SMBG 5.6 vs. iscCGM 6.2 vs. rtCGM 6.5; P = .386). Overall, satisfaction with CGM use was very high; 98% of the CGM users reported better well-being with CGM compared with previous SMBG use. Only 19% of CGM users reported regular data analyses; their HbA1c was lower compared with other CGM users (7.2% ± 1.2% vs. 7.7% ± 1.4%; P = .039).

CONCLUSIONS

In this large sample of young people, 75% were using a CGM system. Treatment satisfaction was very high, but CGM use was not associated with reduced diabetes distress or better glycemic control. However, young people who regularly analyzed their CGM data reported lower HbA1c levels.

RT‐CGM in conjunction with CSII vs MDI in optimizing glycaemic control in T1DM: Systemic review and meta‐analysis

Introduction

To determine the impact of real‐time continuous glucose monitoring (RT‐CGM) in conjunction with ‘Open loop’‐ continuous subcutaneous insulin infusion (CSII) as compared to conventional multiple daily injections (MDI) in type 1 diabetes.

Methods

We explored the COCHRANE database, MEDLINE, WEB OF SCIENCE, GOOGLE SCHOLARS, PUBMED, EMBASE, and cited literature in articles retrieved (2010–2021) for all randomized controlled trials and real‐world trials of more than 6 months duration in patients with type 1 diabetes that compared RT‐CGM+CSII vs RT‐ CGM+MDI. A total of 1645 publications have been identified; however, only 3 trials fulfilled our inclusion criteria with a total number of 150 patients (72 patients using RT‐CGM+CSII and 78 patients on RT‐CGM+MDI). A Systematic Review and Meta‐analysis were carried out.

Results

No statistically significant reduction in HbA1c was found on comparing RT‐CGM+CSII vs RT‐ CGM + MDI, with p‐value = .75. Likewise, impact on TIR, weight and insulin usage was found to be statistically insignificant with p‐value of 0.15, 0.75 and 0.20 respectively. There was an overall homogeneity between the 3 trials in respect to all previous variables with I² being 0%.

Conclusions

Real‐time continuous glucose monitors in conjunction with MDI open‐loop CSII had a similar impact on HbA1c, weight, insulin usage and TIR. In addition, RT‐CGM when combined with CSII was associated with higher costs and reduced quality of life, hence RT‐ CGM+MDI can be considered as a cheaper, safer yet equivalent substitute.

Review Registration

This study was registered in PROSPERO (International prospective register of systematic reviews). Registration Name: RT‐CGM in conjunction with CSII vs MDI in optimizing glycaemic control in T1DM: a systematic review. Registration No: CRD42021255333. Accessible at: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255333. Amendments: Few amendments to the above‐mentioned registration were made: (1) Title (Meta‐analysis was added). (2) Prof. Gleeson was added as an author. (3) Real‐world trials were included. (4) Outcomes required in studies as per our inclusion criteria amended to include at least 1 outcome. (5) Bias risk was assessed by the CASP tool.

Universal Subsidized Continuous Glucose Monitoring Funding for Young People With Type 1 Diabetes: Uptake and Outcomes Over 2 Years, a Population-Based Study

OBJECTIVE

Continuous glucose monitoring (CGM) is increasingly used in type 1 diabetes management; however, funding models vary. This study determined the uptake rate and glycemic outcomes following a change in national health policy to introduce universal subsidized CGM funding for people with type 1 diabetes aged <21 years.

RESEARCH DESIGN AND METHODS

Longitudinal data from 12 months before the subsidy until 24 months after were analyzed. Measures and outcomes included age, diabetes duration, HbA1c, episodes of diabetic ketoacidosis and severe hypoglycemia, insulin regimen, CGM uptake, and percentage CGM use. Two data sources were used: the Australasian Diabetes Database Network (ADDN) registry (a prospective diabetes database) and the National Diabetes Service Scheme (NDSS) registry that includes almost all individuals with type 1 diabetes nationally.

RESULTS

CGM uptake increased from 5% presubsidy to 79% after 2 years. After CGM introduction, the odds ratio (OR) of achieving the HbA1c target of <7.0% improved at 12 months (OR 2.5, P < 0.001) and was maintained at 24 months (OR 2.3, P < 0.001). The OR for suboptimal glycemic control (HbA1c ≥9.0%) decreased to 0.34 (P < 0.001) at 24 months. Of CGM users, 65% used CGM >75% of time, and had a lower HbA1c at 24 months compared with those with usage <25% (7.8 ± 1.3% vs. 8.6 ± 1.8%, respectively, P < 0.001). Diabetic ketoacidosis was also reduced in this group (incidence rate ratio 0.49, 95% CI 0.33-0.74, P < 0.001).

CONCLUSIONS

Following the national subsidy, CGM use was high and associated with sustained improvement in glycemic control. This information will inform economic analyses and future policy and serve as a model of evaluation diabetes technologies.

To sleep or not to sleep: An Italian Control-IQ-uestion

OBJECTIVE

Tandem Control-IQ is an advanced hybrid closed loop (AHCL) system with a Sleep Activity Mode to intensify glycemic control overnight. The aim of the study is to evaluate the effectiveness of using Sleep Mode or not among Tandem Control-IQ users.

RESEARCH DESIGN AND METHODS

We performed a retrospective Tandem Control-IQ data download for patients followed at IRCCS G. Gaslini Pediatric Diabetes Centre. We divided the patients into group 1 (Sleep Mode users) and group 2 (non-users) and compared their overall glycemic data, particularly during nighttime.

RESULTS

Group 1 (n = 49) does not show better nocturnal glycemic control as expected when compared with group 2 (n = 34). Group 2 shows a nighttime TIR% of 69.50 versus 66.25 (p = 0.20). Only the patients who do not use Sleep Mode and with sensor and automatic mode use ≥90% reached TIR >70% during nighttime, as well as lower nocturnal TAR% (18.80 versus 21.78, p = 0.05).

CONCLUSIONS

This is the first study that evaluates the real-life effectiveness of the use of Sleep Mode in young patients with T1D. Control-IQ Sleep Activity Mode may not be as effective in Italian patients as in American patients due to the different habits.

The Association between Treatment Modality, Lipid Profile, Metabolic Control in Children with Type 1 Diabetes and Celiac Disease-Data from the International Sweet Registry

Background and Aims: A higher frequency of dyslipidemia is reported in children with type 1 diabetes (T1D) and celiac disease (CD). Recently, continuous subcutaneous insulin infusion (CSII) has been associated with better lipid profiles in patients with T1D. The aim of this study was to investigate the association between treatment modality and lipid profile, metabolic control, and body mass index (BMI)-SDS in children with both T1D and CD. Methods: Cross-sectional study in children registered in the international SWEET database in November 2020. Inclusion criteria were children (2–18 years) with T1D and CD with available data on treatment modality (CSII and injections therapy, IT), triglyceride, total cholesterol, HDL, LDL, dyslipidemia, HbA1c, and BMI-SDS. Overweight/obesity was defined as > +1 BMI-SDS for age. Data were analyzed by linear and logistical regression models with adjustment for age, gender, and diabetes duration. Results: In total 1009 children with T1D and CD (female 54%, CSII 54%, age 13.9 years ±3.6, diabetes duration 7.2 years ±4.1, HbA1c 7.9% ±1.4) were included. Significant differences between children treated with CSII vs. IT were respectively found; HDL 60.0 mg/dL vs. 57.8 mg/dL, LDL 89.4 mg/dL vs. 94.2 mg/dL, HbA1c 7.7 vs. 8.1%, BMI-SDS 0.4 vs. 0.6, overweight and obesity 17% vs. 26% (all p < 0.05). Conclusions: CSII is associated with higher HDL and lower LDL, HbA1c, BMI-SDS, and percentage of overweight and obesity compared with IT in this study. Further prospective studies are required to determine whether CSII improves lipid profile, metabolic control and normalize body weight in children with both T1D and CD.

Effectiveness of a closed-loop control system and a virtual educational camp for children and adolescents with type 1 diabetes: A prospective, multicentre, real-life study

AIM

To evaluate the impact of a virtual educational camp (vEC) on glucose control in children and adolescents with type 1 diabetes using a closed-loop control (CLC) system.

MATERIALS AND METHODS

This was a prospective multicentre study of children and adolescents with type 1 diabetes using the Tandem Basal-IQ system. Insulin pumps were upgraded to Control-IQ, and children and their parents participated in a 3-day multidisciplinary vEC. Clinical data, glucose metrics and HbA1c were evaluated over the 12 weeks prior to the Control-IQ update and over the 12 weeks after the vEC.

RESULTS

Forty-three children and adolescents (aged 7-16 years) with type 1 diabetes and their families participated in the vEC. The median percentage of time in target range (70-180 mg/dL; TIR) increased from 64% (interquartile range [IQR] 56%-73%) with Basal-IQ to 76% (IQR 71%-81%) with Control-IQ (P < .001). After the vEC, more than 75% of participants achieved a TIR of more than 70%. The percentage of time between 180 and 250 mg/dL and above 250 mg/dL decreased by 5% (P < .01) and 6% (P < .01), respectively, while the time between 70 and 54 mg/dL and below 54 mg/dL remained low and unaltered. HbA1c decreased by 0.5% (P < .01). There were no episodes of diabetic ketoacidosis or severe hypoglycaemia.

CONCLUSIONS

In this study of children managing their diabetes in a real-world setting, more than 75% of children who participated in a vEC after starting a CLC system could obtain and maintain a TIR of more than 70%. The vEC was feasible and resulted in a significant and persistent improvement in TIR in children and adolescents with type 1 diabetes.

Rethinking Carbohydrate Intake and Time in Range in Children and Adolescents with Type 1 Diabetes

The aim of this study was to evaluate the association between macronutrient intake and time in range (TIR) of 70-180 mg/dL in children and adolescents with type 1 diabetes (T1D). A multi-center study recruited patients with T1D using continuous glucose monitoring (CGM) between January 2019 and January 2020 from centers across Italy. Diet intake was recorded using three-day weighed food diaries. Nutrients were evaluated as percentages of total intake. TIR was considered at target if the percentage of readings was higher than 70%. Clinical and nutritional factors associated with TIR at target were analyzed using multiple correspondence analysis and multiple logistic regression. Data from 197 participants (53% male, median age 11.6 years, median HbA1c 55.2 mmol/mol, median TIR 60%) were analyzed. Macronutrient intake was 45.9% carbohydrates, 16.9% protein, 37.3% fat, and 13.1 g/day fiber (median values). TIR > 70% was observed in 28% of participants; their diet contained more protein (17.6%, p = 0.015) and fiber (14.4 g/day, p = 0.031) than those not at target. The probability of having a TIR > 70% was significantly higher with 40-44% consumption of carbohydrates compared with 45-50% consumption of carbohydrates and with the use of a carbohydrate counting system. Based on these results, a five percent reduction in the percentage of carbohydrate intake can help children and adolescents with T1D achieve the goal of a TIR > 70%. Both a lower and higher percentage of carbohydrate intake appears to reduce the probability of reaching the target TIR > 70%. These results require validation in other populations before being used in clinical practice.

Clinical and Demographic Factors Associated With Diabetic Retinopathy Among Young Patients With Diabetes

IMPORTANCE

Diabetic retinopathy (DR) is a leading cause of vision loss worldwide. As the incidence of both type 1 and type 2 diabetes among youths continues to increase around the world, understanding the factors associated with the development of DR in this age group is important.

OBJECTIVE

To identify factors associated with DR among children, adolescents, and young adults with type 1 or type 2 diabetes in the US.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study pooled data from 2 large academic pediatric centers in the US (Baylor College of Medicine/Texas Children's Hospital [BCM/TCH] Diabetes and Endocrine Care Center and Johns Hopkins University [JHU] Pediatric Diabetes Center) to form a diverse population for analysis. Data were collected prospectively at the JHU center (via point-of-care screening using fundus photography) from December 3, 2018, to November 1, 2019, and retrospectively at the BCM/TCH center (via electronic health records of patients who received point-of-care screening using retinal cameras between June 1, 2016, and May 31, 2019). A total of 1640 individuals aged 5 to 21 years with type 1 or type 2 diabetes (308 participants from the JHU center and 1332 participants from the BCM/TCH center) completed DR screening and had gradable images.

MAIN OUTCOME AND MEASURES

Prevalence of DR, as identified on fundus photography, and factors associated with DR.

RESULTS

Among 1640 participants (mean [SD] age, 15.7 [3.6] years; 867 female individuals [52.9%]), 1216 (74.1%) had type 1 diabetes, and 416 (25.4%) had type 2 diabetes. A total of 506 participants (30.9%) were Hispanic, 384 (23.4%) were non-Hispanic Black or African American, 647 (39.5%) were non-Hispanic White, and 103 (6.3%) were of other races or ethnicities (1 was American Indian or Alaska Native, 50 were Asian, 1 was Native Hawaiian or Pacific Islander, and 51 did not specify race or ethnicity, specified other race or ethnicity, or had unavailable data on race or ethnicity). Overall, 558 of 1216 patients (45.9%) with type 1 diabetes used an insulin pump, and 5 of 416 patients (1.2%) with type 2 diabetes used an insulin pump. Diabetic retinopathy was found in 57 of 1640 patients (3.5%). Patients with DR vs without DR had a greater duration of diabetes (mean [SD], 9.4 [4.4] years vs 6.6 [4.4] years; P < .001) and higher hemoglobin A1c (HbA1c) levels (mean [SD], 10.3% [2.4%] vs 9.2% [2.1%]; P < .001). Among those with type 1 diabetes, insulin pump use was associated with a lower likelihood of DR after adjusting for race and ethnicity, insurance status, diabetes duration, and HbA1c level (odds ratio [OR], 0.43; 95% CI, 0.20-0.93; P = .03). The likelihood of having DR was 2.1 times higher among Black or African American participants compared with White participants (OR, 2.12; 95% CI, 1.12-4.01; P = .02); this difference was no longer significant after adjusting for duration of diabetes, insurance status, insulin pump use (among patients with type 1 diabetes only), and mean HbA1c level (type 1 diabetes: OR, 1.79; 95% CI, 0.83-3.89; P = .14; type 2 diabetes: OR, 1.08; 95% CI, 0.30-3.85; P = .91).

CONCLUSIONS AND RELEVANCE

This study found that although the duration of diabetes and suboptimal glycemic control have long been associated with DR, insulin pump use (among those with type 1 diabetes) was independently associated with a lower likelihood of DR, which is likely owing to decreased glycemic variability and increased time in range (ie, the percentage of time blood glucose levels remain within the 70-180 mg/dL range). Black or African American race was found to be associated with DR in the univariable analysis but not in the multivariable analysis, which may represent disparities in access to diabetes technologies and care.

Time-in-range for monitoring glucose control: Is it time for a change?

The HbA1c value has been the gold standard for evaluating glucose control for decades. However, it has limitations such as the lack of information on glycemic variability or the risk of hypoglycemia. The increasing use of continuous glucose monitoring has provided patients and healthcare professionals with a range of useful metrics for the management of diabetes. Among them, Time in Range (TIR) is a simple and intuitive metric that gives information regarding the quality of glucose control. It is defined as the time spent in an individual's target glucose range. TIR is strongly correlated with HbA1c, and it has been linked to the risk of developing microvascular and macrovascular complications. The International Consensus on Time in Range has recently set targets for different diabetes populations. For the majority of people with type 1 or type 2 diabetes, a TIR (70-180 mg/dL or 3.9-10.0 mmol/L) of >70%, a time below range (TBR) <70 mg/dL (<3.9 mmol/L) of <4% and a TBR <54 (<3.0 mmol/L) of <1% are recommended. In this review, we address the latest evidence for the use of TIR as an essential parameter in the management of diabetes.

Technological Ecological Momentary Assessment Tools to Study Type 1 Diabetes in Youth: Viewpoint of Methodologies

Type 1 diabetes (T1D) is one of the most common chronic childhood diseases, and its prevalence is rapidly increasing. The management of glucose in T1D is challenging, as youth must consider a myriad of factors when making diabetes care decisions. This task often leads to significant hyperglycemia, hypoglycemia, and glucose variability throughout the day, which have been associated with short- and long-term medical complications. At present, most of what is known about each of these complications and the health behaviors that may lead to them have been uncovered in the clinical setting or in laboratory-based research. However, the tools often used in these settings are limited in their ability to capture the dynamic behaviors, feelings, and physiological changes associated with T1D that fluctuate from moment to moment throughout the day. A better understanding of T1D in daily life could potentially aid in the development of interventions to improve diabetes care and mitigate the negative medical consequences associated with it. Therefore, there is a need to measure repeated, real-time, and real-world features of this disease in youth. This approach is known as ecological momentary assessment (EMA), and it has considerable advantages to in-lab research. Thus, this viewpoint aims to describe EMA tools that have been used to collect data in the daily lives of youth with T1D and discuss studies that explored the nuances of T1D in daily life using these methods. This viewpoint focuses on the following EMA methods: continuous glucose monitoring, actigraphy, ambulatory blood pressure monitoring, personal digital assistants, smartphones, and phone-based systems. The viewpoint also discusses the benefits of using EMA methods to collect important data that might not otherwise be collected in the laboratory and the limitations of each tool, future directions of the field, and possible clinical implications for their use.

Beyond A1C: A Practical Approach to Interpreting and Optimizing Continuous Glucose Data in Youth

Despite significant pharmacological and technological advances in the treatment of type 1 diabetes, the majority of youth in the United States do not meet the American Diabetes Association's recommended A1C goal. Understanding and managing glycemic variability is important in children and adolescents. Because A1C provides an incomplete picture of day-to-day glycemic fluctuations, continuous glucose monitoring (CGM)-derived metrics are a promising addition to address glycemic management challenges in youth with diabetes. In this article, we discuss how to develop practical strategies to optimize the use of CGM in the pediatric population, interpret the valuable data it provides, and develop personalized and actionable treatment goals.

A Comparison of Two Hybrid Closed-Loop Systems in Italian Children and Adults With Type 1 Diabetes

Tandem Control-IQ and Minimed 780G represent the most Advanced Hybrid Closed Loop (AHCL) systems currently available in pediatric and adult subjects with Type 1 Diabetes (T1D). We retrospectively compared clinical and continuous glucose monitoring data from 51 patients who upgraded to Minimed 780G system and have completed 1-month observation period with data from 39 patients who upgraded to Tandem Control-IQ. Inverse probability weighting was used to minimize the basal characteristics imbalances. Both AHCL systems showed a significant improvement in glycemic parameters. Minimed 780G group achieved higher TIR increase (p= 0.004) and greater reduction of blood glucose average (p= 0.001). Tandem Control-IQ system significantly reduced the occurrence of TBR (p= 0.010) and the Coefficient of Variation of glucose levels (p= 0.005). The use of ACHL systems led to a significant improvement of glycemic control substantially reaching the International recommended glycemic targets. Minimed 780G appears to be more effective in managing hyperglycemia, while Tandem Control-IQ seems to be more effective in reducing time in hypoglycemia.

Self-management among pre-teen and adolescent diabetes device users

OBJECTIVE

Despite increased diabetes device use, few adolescents with type 1 diabetes (T1D) meet glycemic targets. We examine associations between utilization of insulin pumps and continuous glucose monitoring (CGM) and glycemic control.

RESEARCH DESIGN AND METHODS

This prospective cohort study included 80 youths (10-18 years of age) with T1D. Multiple linear regression and linear mixed models (LMM) were used to estimate the effects of device self-management on HbA1c and daily time in range (70-180 mg/dL), respectively.

RESULTS

Every blood glucose (BG) input/day was associated with a 0.2% decrease in HbA1c (95% CI: -0.297, -0.013), each bolus/day was associated with a 0.2% decrease (-0.327, -0.057), and use of CGM was associated with a 0.5% decrease (-1.00, -0.075). Among CGM users (n = 45) every 10% increase in CGM use was associated with a 0.3% decrease in HbA1c (-0.390, -0.180). In LMM accounting for within subject and between subject variability, there was a negative association between BG input/day frequency (coefficient = -1.880, [-2.640, -1.117]) and time in range. Residual random effects for CGM users were large showing time in range varied between youth with a SD of 15.0% (3 hours and 36 minutes) (SE 2.029, [11.484, 19.530]). Time in range varied significantly from day-to-day with SD of 18.6% (4 hours and 40 minutes) (SE0.455, [17.690, 19.473]).

CONCLUSIONS

Device self-management behaviors among youth are significantly associated with both HbA1c and time in range. Our findings showing an association between reduced time in range and increased self-management behaviors is novel and deserves further investigation.

Lessons learned from the continuous glucose monitoring metrics in pediatric patients with type 1 diabetes under COVID-19 lockdown

AIMS

Billions of people have been under lockdown in an attempt to prevent COVID-19 spread. Lifestyle changes during lockdown could lead to deterioration of glycemic control in type 1 diabetes (T1D). We aimed to assess the impact of COVID-19 lockdown on the glycemic control of pediatric patients with T1D.

METHODS

This observational real-life study from the AWeSoMe Group assessed continuous glucose monitoring (CGM) metrics of 102 T1D patients (52.9% males, mean age 11.2 ± 3.8 years, mean diabetes duration 4.2 ± 3.8 years) who used  Dexcom G5. The data were accessed without any interface between patients, caregivers, and the diabetes team. Study variables from CGM metrics were: mean glucose level, time-in-range (TIR, 70-180 mg/dL; 3.9-10 mmol/L), hypoglycemia (< 54 mg/dL; < 3 mmol/L), hyperglycemia (> 250 mg/dL; > 13.3 mmol/L), coefficient of variation (CV), and time CGM active before and during lockdown. Delta-variable = lockdown variable minus before-lockdown variable.

RESULTS

The mean TIR was 60.9 ± 14.3% before lockdown, with no significant change during lockdown (delta-TIR was 0.9 ± 7.9%). TIR during lockdown was significantly correlated with TIR before lockdown (r = 0.855, P < 0.001). Patients with improved TIR (delta-TIR > 3%) were significantly older than patients with stable or worse TIR (P = 0.028). Children aged < 10 years had a significantly higher CV before lockdown and during lockdown than children aged ≥ 10 years (P = 0.02 and P = 0.005, respectively). Among children aged < 10 years, a multiple linear regression model revealed associations of age and lower socioeconomic cluster with delta-TIR (F = 4.416, P = 0.019) and with delta-mean glucose (F = 4.459, P = 0.018).

CONCLUSIONS

CGM metrics in pediatric patients with T1D were relatively stable during a nationwide lockdown. Intervention plans should focus on younger patients with lower socioeconomic position.

Comparison of the effects of lockdown due to COVID-19 on glucose patterns among children, adolescents, and adults with type 1 diabetes: CGM study

INTRODUCTION

The COVID-19 pandemic forced the Italian government to issue extremely restrictive measures on daily activities since 11 March 2020 ('lockdown'), which may have influenced the metabolic control of type 1 diabetes mellitus (T1D). The aims of the study were to investigate continuous glucose monitoring (CGM) metrics in children and adults with T1D during lockdown and to identify their potentially related factors.

RESEARCH DESIGN AND METHODS

We enrolled 130 consecutive patients with T1D (30 children (≤12 years), 24 teenagers (13-17 years), and 76 adults (≥18 years)) using either Dexcom or FreeStyle LibreCGM>70% during the study period, without hybrid closed-loop insulin pump. CGM metrics during the 20 days before and the 20 days after lockdown were calculated. By telephonic contact, we performed validated physical activity and perceived stress questionnaires.

RESULTS

In children, significantly lower glucose SD (SDglu) (p=0.029) and time below range (TBR)<54 mg/dL (TBR2) (p=0.029) were detected after lockdown. CGM metrics were comparable in teenagers before and during lockdown. After lockdown, adults improved significantly time in range (TIR) 70-180 mg/dL (p<0.001) and remaining metrics, except percent coefficient of variation and TBR2. In adults, considering the changes in SDglu and TIR occurred before and during lockdown, we identified a group with improved TIR and SDglu who performed more physical activity, one with improved glucose variability who was younger than the other patients, and one with worsened glucose variability who showed higher perceived stress than others.

CONCLUSION

In patients with T1D during lockdown, CGM metrics mostly improved in children and adults, whereas it was unchanged in teenagers. In adults, age, physical activity, and perceived stress may be relevant contributing factors.

Severe Hypoglycemia: Is It Still a Threat for Children and Adolescents With Type 1 Diabetes?

Severe hypoglycemia is defined as a condition with serious cognitive dysfunction, such as a convulsion and coma, requiring external help from other persons. This condition is still lethal and is reported to be the cause of death in 4-10% in children and adolescents with type 1 diabetes. The incidence of severe hypoglycemia in the pediatric population was previously reported as high as more than 50-100 patient-years; however, there was a decline in the frequency of severe hypoglycemia during the past decades, and relationship with glycemic control became weaker than previously reported. A lot of studies have shown the neurological sequelae with severe hypoglycemia as cognitive dysfunction and abnormalities in brain structure. This serious condition also provides negative psychosocial outcomes and undesirable compensatory behaviors. Various possible factors, such as younger age, recurrent hypoglycemia, nocturnal hypoglycemia, and impaired awareness of hypoglycemia, are possible risk factors for developing severe hypoglycemia. A low HbA_1c level is not a predictable value for severe hypoglycemia. Prevention of severe hypoglycemia remains one of the most critical issues in the management of pediatric patients with type 1 diabetes. Advanced technologies, such as continuous glucose monitoring (CGM), intermittently scanned CGM, and sensor-augmented pump therapy with low-glucose suspend system, potentially minimize the occurrence of severe hypoglycemia without worsening overall glycemic control. Hybrid closed-loop system must be the most promising tool for achieving optimal glycemic control with preventing the occurrence of severe hypoglycemia in pediatric patients with type 1 diabetes.