Youth and non-European ethnicity are associated with increased loss of publicly funded insulin pump access in New Zealand people with type 1 diabetes

Protocol for a prospective, multicenter, parallel-group, open-label randomized controlled trial comparing standard care with Closed lOoP In chiLdren and yOuth with Type 1 diabetes and high-risk glycemic control: the CO-PILOT trial

Purpose

Advanced hybrid closed loop (AHCL) systems have the potential to improve glycemia and reduce burden for people with type 1 diabetes (T1D). Children and youth, who are at particular risk for out-of-target glycemia, may have the most to gain from AHCL. However, no randomized controlled trial (RCT) specifically targeting this age group with very high HbA1c has previously been attempted. Therefore, the CO-PILOT trial (Closed lOoP In chiLdren and yOuth with Type 1 diabetes and high-risk glycemic control) aims to evaluate the efficacy and safety of AHCL in this group.

Methods

A prospective, multicenter, parallel-group, open-label RCT, comparing MiniMed™ 780G AHCL to standard care (multiple daily injections or continuous subcutaneous insulin infusion). Eighty participants aged 7-25 years with T1D, a current HbA1c ≥ 8.5% (69 mmol/mol), and naïve to automated insulin delivery will be randomly allocated to AHCL or control (standard care) for 13 weeks. The primary outcome is change in HbA1c between baseline and 13 weeks. Secondary outcomes include standard continuous glucose monitor glycemic metrics, psychosocial factors, sleep, platform performance, safety, and user experience. This RCT will be followed by a continuation phase where the control arm crosses over to AHCL and all participants use AHCL for a further 39 weeks to assess longer term outcomes.

Conclusion

This study will evaluate the efficacy and safety of AHCL in this population and has the potential to demonstrate that AHCL is the gold standard for children and youth with T1D experiencing out-of-target glucose control and considerable diabetes burden.

Trial registration

This trial was prospectively registered with the Australian New Zealand Clinical Trials Registry on 14 November 2022 (ACTRN12622001454763) and the World Health Organization International Clinical Trials Registry Platform (Universal Trial Number U1111-1284-8452).

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-024-01397-4.

Interviews with Indigenous Māori with type 1 diabetes using open-source automated insulin delivery in the CREATE randomised trial

Purpose

Open-source automated insulin delivery (AID) is used by thousands of people with type 1 diabetes (T1D), but has unknown generalisability to marginalised ethnic groups. This study explored experiences of Indigenous Māori participants in the CREATE trial with use of an open-source AID system to identify enablers/barriers to health equity.

Methods

The CREATE randomised trial compared open-source AID (OpenAPS algorithm on an Android phone with a Bluetooth-connected pump) to sensor-augmented pump therapy. Kaupapa Māori Research methodology was used in this sub-study. Ten semi-structured interviews with Māori participants (5 children, 5 adults) and whānau (extended family) were completed. Interviews were recorded and transcribed, and data were analysed thematically. NVivo was used for descriptive and pattern coding.

Results

Enablers/barriers to equity aligned with four themes: access (to diabetes technologies), training/support, operation (of open-source AID), and outcomes. Participants described a sense of empowerment, and improved quality of life, wellbeing, and glycaemia. Parents felt reassured by the system’s ability to control glucose, and children were granted greater independence. Participants were able to use the open-source AID system with ease to suit whānau needs, and technical problems were manageable with healthcare professional support. All participants identified structures in the health system precluding equitable utilisation of diabetes technologies for Māori.

Conclusion

Māori experienced open-source AID positively, and aspired to use this therapy; however, structural and socio-economic barriers to equity were identified. This research proposes strength-based solutions which should be considered in the redesign of diabetes services to improve health outcomes for Māori with T1D.

Trial Registration: The CREATE trial, encompassing this qualitative sub-study, was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12620000034932p) on the 20^th January 2020.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-023-01215-3.

A Self-Compassion Chatbot to Improve the Wellbeing of Adolescents with Type 1 Diabetes During the COVID-19 Pandemic: What do Adolescents and their Healthcare Professionals Want?

BACKGROUND

Prior to the coronavirus (COVID-19) pandemic, adolescents with type 1 diabetes (T1D) already experienced far greater rates of psychological distress than their peers. With the pandemic further challenging mental health and increasing the barriers to maintaining optimal diabetes self-management, it is vital this population has access to remotely deliverable, evidence-based interventions to improve psychological and diabetes outcomes. Chatbots, defined as digital conversational agents, offer these unique advantages, as well as the ability to engage in empathetic and personalized conversations 24/7. Building on previous work developing a self-compassion program for adolescents with T1D, a self-compassion chatbot was developed for adolescents with T1D to address these concerns. However, the acceptability and potential clinical usability of a chatbot to deliver self-compassion coping tools to adolescents with T1D remained unknown.

OBJECTIVE

This qualitative study was designed to evaluate the acceptability and potential clinical utility of a novel self-compassion chatbot (called 'COMPASS') among adolescents aged 12 to 16 years with T1D and their diabetes healthcare professionals.

METHODS

Potential adolescent participants were recruited from previous participant lists, and online and in-clinic study flyers, whereas healthcare professionals were recruited from clinic emails and diabetes research special interest groups. Qualitative Zoom interviews exploring views on a newly developed self-compassion chatbot were conducted with 19 adolescents (in 4 focus groups), and 11 diabetes healthcare professionals (in 2 focus groups and 6 individual interviews), from March to April 2022. Transcripts were analyzed using directed content analysis to examine the features and content of greatest importance to both groups.

RESULTS

Adolescents were broadly representation of the youth population living with T1D in Aotearoa (58% female, 68% Aotearoa New Zealand European, 11% Māori). Healthcare professionals represented a range of disciplines including Diabetes Nurse Specialists (n = 3), Health Psychologists (n = 3), Dieticians (n = 3), and Endocrinologists (n = 2). Findings offer early insight into what adolescents with T1D and their healthcare professionals see as shared advantages of COMPASS and desired future additions, such as personalization (mentioned by all 19 adolescents), self-management support (mentioned by 13 of 19 adolescents), clinical utility (mentioned by all 11 healthcare professionals), and breadth and flexibility of tools (mentioned by 10 of 11 healthcare professionals).

CONCLUSIONS

Early data suggest that a self-compassion chatbot for adolescents with T1D is acceptable, relevant to common difficulties, and offers clinical utility during the COVID-19 pandemic. However, shared desired features amongst both groups, including problem-solving and integration with diabetes technology to support self-management, creating a safe peer-to-peer sense of community, and broadening the representation of different cultures, lived experience stories, and diabetes challenges, could further improve the potential of the chatbot. Based on these findings, the COMPASS chatbot is currently being improved to be tested in a future feasibility study.

CLINICALTRIAL

Design of an open source ultra low cost insulin pump

In this report we present a design for an open source low cost insulin pump. The pump has been designed to provide an alternative to commercially available pumps costing upwards of US$6500, making them inaccessible to many. The hardware described in this article can be produced for a materials cost of US$89.85. Compared to other devices on the market, the design presented has the obvious advantage of being low cost, but is also highly customisable as it is run using open source software. The device is housed in a case of size 85 mm x 55 mm x 25 mm making it small enough to fit in a pocket, and equivalent to other devices on the market. The device is designed to work with insulin cartridges currently available on the market. Power is provided through the use of AAA batteries, and the pump is able to be recharged through a USB mini port. The accuracy of the pump has been tested and compared to data obtained from an in-warranty commercial insulin pump model using an identical testing methodology, with the ultra-low-cost pump performing similarly to the commercial model. The system can be readily extended to be controlled from external bluetooth or wired mobile devices using their built in security, offloading computation from the device and onto a phone.

The role of protective psychological factors, self-care behaviors, and HbA1c in young adults with type 1 diabetes

OBJECTIVE

To investigate whether protective psychological factors in young adults with type 1 diabetes are associated with more optimal self-care behaviors and HbA1c, and to explore possible mediators between protective psychological factors and HbA1c.

RESEARCH DESIGN AND METHODS

This cross-sectional study examined the associations between protective psychological factors (optimism, positive efficacy expectancies, and self-compassion), maladaptive psychological factors (depression, anxiety, and stress), self-care behaviors, and HbA1c in 113 young adults (17-25 years) with type 1 diabetes in Auckland, New Zealand. Pearson's correlations, multiple linear regressions, and multiple mediation analyses were used to examine associations and mediators.

RESULTS

Higher positive efficacy expectancies (beliefs about coping with difficulties) were associated with more optimal HbA1c (β = -0.26, 95% CI: -1.99 to -0.45) and more optimal self-care behaviors (β = 0.33, 95% CI: 0.28 to 0.92) in the adjusted models. Higher levels of self-compassion were associated with more optimal self-care behaviors (β = 0.27, 95% CI: 0.09 to 0.43). Depression was associated with less optimal self-care behaviors (β = -0.35, 95% CI: -1.33 to -0.43) and stress was associated with less optimal HbA1c (β = 0.26, 95% CI: 0.27 to 1.21). Mediation results suggested that self-care behaviors mediated the relationship between all three of the protective psychological factors and more optimal HbA1c, and that lower stress also mediated the relationship between higher self-compassion and more optimal HbA1c.

CONCLUSIONS

This study adds to the emerging literature that protective psychological factors may play an adaptive role in improving health outcomes in young adults with type 1 diabetes. Interventions targeting protective psychological factors present a promising approach to optimizing wellbeing and self-care in youth with type 1 diabetes.

Use of intermittently scanned continuous glucose monitoring in young people with high-risk type 1 diabetes-Extension phase outcomes following a 6-month randomized control trial

AIMS

To describe the impact of a 12-month intervention using intermittently scanned continuous glucose monitoring (isCGM) on glycaemic control and glucose test frequency in adolescents and young adults with type 1 diabetes (T1D) and high-risk glycaemic control (HbA_1c ≥75 mmol/mol [≥9.0%]).

METHODS

In total, 64 young people (aged 13-20 years, 16.6 ± 2.1 years; 48% female; 41% Māori or Pacific ethnicity; mean diabetes duration 7.5 ± 3.8 years) with T1D were enrolled in a 6-month, randomized, parallel-group study comparing glycaemic outcomes from the isCGM intervention (n = 33) to self monitoring blood glucose (SMBG) controls (n = 31). In this 6-month extension phase, both groups received isCGM; HbA_1c , glucose time-in-range (TIR), and combined glucose test frequency were assessed at 9 and 12 months.

RESULTS

At 12 months, the mean difference in HbA_1c from baseline was -4 mmol/mol [-0.4%] (95% confidence interval, CI: -8, 1 mmol/mol [-0.8, 0.1%]; p = 0.14) in the isCGM intervention group, and -7 mmol/mol [-0.7%] (95% CI: -16, 1 mmol/mol [-1.5, 0.1%]; p = 0.08) in the SMBG control group. No participants achieved ≥70% glucose TIR (3.9-10.0 mmol/L). The isCGM intervention group mean rate of daily glucose testing was highest at 9 months, 2.4 times baseline rates (p < 0.001), then returned to baseline by 12 months (incidence rate ratio = 1.4; 95% CI: 0.9, 2.1; p = 0.091).

CONCLUSIONS

The use of isCGM in young people with high-risk T1D resulted in transient improvements in HbA_1c and glucose monitoring over a 9-month time frame; however, benefits were not sustained to 12 months.

A comparison of FreeStyle Libre 2 to self-monitoring of blood glucose in children with type 1 diabetes and sub-optimal glycaemic control: a 12-week randomised controlled trial protocol

Purpose

Frequent glucose monitoring is necessary for optimal glycaemic control. Second-generation intermittently scanned glucose monitoring (isCGM) systems inform users of out-of-target glucose levels and may reduce monitoring burden. We aim to compare FreeStyle Libre 2 (Abbott Diabetes Care, Witney, U.K.) to self-monitoring of blood glucose in children with type 1 diabetes and sub-optimal glycaemic control.

Methods

This open-label randomised controlled trial will enrol 100 children (4–13 years inclusive, diagnosis of type 1 diabetes ≥ 6 months, HbA1c 58–110 mmol/mol [7.5–12.2%]), from 5 New Zealand diabetes centres. Following 2 weeks of blinded sensor wear, children will be randomised 1:1 to control or intervention arms. The intervention (duration 12 weeks) includes second-generation isCGM (FreeStyle Libre 2) and education on using interstitial glucose data to manage diabetes. The control group will continue self-monitoring blood glucose. The primary outcome is the difference in glycaemic control (measured as HbA1c) between groups at 12 weeks. Pre-specified secondary outcomes include change in glucose monitoring frequency, glycaemic control metrics and psychosocial outcomes at 12 weeks as well as isCGM acceptability.

Discussion

This research will investigate the effectiveness of the second-generation isCGM to promote recommended glycaemic control. The results of this trial may have important implications for including this new technology in the management of children with type 1 diabetes.

Trial registration

This trial was prospectively registered with the Australian New Zealand Clinical Trials Registry on 19 February 2020 (ACTRN12620000190909p) and the World Health Organization International Clinical Trials Registry Platform (Universal Trial Number U1111-1237-0090).

Exploring the views of adolescents with type 1 diabetes on digital mental health interventions: What functionality and content do they want?

BACKGROUND

Adolescents with type 1 diabetes (T1D) experience higher rates of psychological disorders compared with their healthy peers. As poor psychological health has been associated with suboptimal glycaemic control and more frequent complications, there is an urgent need to develop more 'clinically usable' interventions. Digital mental health interventions offer unique advantages compared with in-person interventions; however, what adolescents with T1D want in terms of content and functionality is poorly understood. Accordingly, the current study conducted focus groups to examine the views of adolescents with T1D regarding digital mental health interventions.

METHODS

Four focus groups were conducted, including 16 adolescents with T1D, ranging from 13 to 17 years in age (69% female). Transcripts were analysed using directed content analysis to examine (1) 'what adolescents dislike about existing digital mental health interventions?' and (2) 'what adolescents want in future digital mental health interventions?'.

RESULTS

Findings provide a preliminary understanding of what adolescents dislike and also the type of content and functional features, which may be important to include in digital mental health programs for this population, such as a peer support feature (reported by 16 of 16), emotion and diabetes check-in feature (11 of 16) and diabetes-relevant content (12 of 16).

CONCLUSIONS

Early data suggest that digital mental health interventions should include a significant peer support element, diabetes-relevant content and examples, and check-in on their mental health and diabetes self-management regularly, while avoiding fixed responses or modules and non-age-appropriate content. Based on these findings, a digital intervention is currently being developed.