Why is cognitive dysfunction associated with the development of diabetes early in life? The diathesis hypothesis

Impact of continuous glucose monitoring on everyday life of young children with type 1 diabetes and their parents: An evaluation of 114 families

INTRODUCTION

The prevalence of type 1 diabetes is increasing worldwide. The advent of new monitoring devices has enabled tighter glycemic control.

AIM

To study the impact of glucose monitoring devices on the everyday life of young children with type 1 diabetes (T1D) and their parents.

METHODS

A questionnaire was addressed to parents of children with T1D under the age of 6 years with an insulin pump treated in one of the hospitals of the ADIM network in France between January and July 2020.

RESULTS

Among the 114 families included in the study, 53% of parents (26/49) woke up every night to monitor blood glucose levels when their child had flash glucose monitoring (FGM), compared with 23% (13/56) of those whose child had continuous glucose monitoring (CGM). Overall, 81% of parents (86/108) found that glucose monitoring improved their own sleep and parents whose child had CGM were significantly more likely to report improved sleep (86% vs 73%, p = 0.006). Forty-nine percent of parents (55/113) declared that they (in 87% of cases, the mother only) had reduced their working hours or stopped working following their child's T1D diagnosis. Maternal unemployment was significantly associated with the presence of siblings (p = 0.001) but not with glycemic control (p = 0,87). Ninety-eight percent of parents (105/107) think that glucose monitoring improves school integration.

CONCLUSION

In these families of children with T1D, new diabetes technologies reduced the burden of care but sleep disruption remained common. Social needs evaluation, particularly of mothers, is important at initial diagnosis of T1D in children.

14. Children and Adolescents: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

The relationship between diabetic ketoacidosis and suicidal or self-injurious behaviour: A systematic review

Background

It has been suggested that there may be an association between type 1 diabetes (T1DM) and suicide, with one study reporting a rate 11 times that of the general population The aim of this paper was to investigate the association between Diabetic ketoacidosis (DKA: a life-threatening acute complication of T1DM) and suicidal behaviours in people with T1DM.

Methods

We performed a search of the following databases: PubMed, PsychInfo, and Embase for papers which explored the association between suicidal behaviours and self-harm with DKA in T1DM. We excluded case reports and review papers.

Results

Only three papers explored the relationship between DKA and self-harm. One study found an association between DKA and self-harm in a national cohort of people with type 1 diabetes and schizophrenia. The second found a significant increase in psychiatric admissions for self-harm following an episode of DKA. The third study reported that patients with diabetes and a history of self-harm were at elevated risk of a range of diabetes complications including DKA. These findings indicate an association between DKA and self-harm and support the guidelines in recommending a psychosocial assessment where DKA cannot be explained.

Conclusions

This review suggests that DKA is associated with suicidal or self-injurious behaviours. The small number of studies and the seriousness of this issue highlight the importance of further research on this topic, to improve the evidence base for the identification and treatment of risk of suicidal behaviours in people with T1DM.

A comparative study using insulin pump therapy and continuous glucose monitoring in newly diagnosed very young children with type 1 diabetes: it is possible to bend the curve of HbA1c

AIMS

The target of metabolic control (HbA1c < 7% or 53 mmol/mol) recommended by the ADA and ISPAD is attained by 30% of children with Type 1 Diabetes (T1D). Advances in technologies for T1D aim to improve metabolic outcomes and reduce complications. This observational study assesses the long-term outcomes of advanced technologies for treatment of T1D compared to conventional approach started at onset in a group of very young children with T1D.

METHODS

54 patients with less 4 years old at onset of T1D were enrolled and followed for up to 9 years after diagnosis. 24 subjects started continuous subcutaneous insulin (CSII) treatment and 30 subjects received MDI therapy from onset. Auxological data, HbA1c and total daily insulin dose (TDD/kg) have been collected at admission and every 4 months. HbA1cAUC>6%, rates of acute complications, glycemic variability indices and glucometrics were also recorded.

RESULTS

Patients with CSII therapy had significantly lower mean HbA1c values compared to subjects receiving MDI treatment. CSII approach also recorded lower mean HbA1cAUC>6% and TDD/kg than MDI therapy. At the last download data, the time in range (TIR) was higher in patients with CSII and hyperglycemia events were lower. Better glycemic variability indices have been described during CSII therapy, including mean glycemia, standard deviation, coefficient of variation (CV), glycemia risk index (GRI) and high blood glucose index (HBGI). There was no statistically significant difference between frequency of severe hypoglycemia and ketoacidosis episodes between groups.

CONCLUSIONS

Early initiation of diabetes technologies is safe and able to determine a better long term glycemic control in young children with T1D. It also allows to flatten the trajectory of HbA1c, probably reducing microvascular, macrovascular and neurological complications of diabetes in this very peculiar age group.

Assessment of executive function in a rodent model of Type 1 diabetes

This study examined the impact of Type 1 Diabetes Mellitus (T1DM) on executive function using a series of operant conditioning-based tasks in rats. Sprague Dawley rats were randomized to either non-diabetic (n = 12; 6 male) or diabetic (n = 14; 6 male) groups. Diabetes was induced using multiple low-dose streptozotocin injections. All diabetic rodents were insulin-treated using subcutaneous insulin pellet implants (9-15 mM). At week 14 of the study, rats were placed on a food restricted diet to induce 5-10 % weight loss. Rodents were familiarized and their set-shifting ability was tested on a series of tasks that required continuous adjustments to novel stimulus-reward paradigms in order to receive food rewards. Results showed no differences in the number of trials, nor number and type of errors made to successfully complete each task between groups. Therefore, we report no differences in executive function, or more specifically set-shifting abilities between non-diabetic and diabetic rodents that receive insulin.

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

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

Missed meal boluses and poorer glycemic control impact on neurocognitive function may be associated with white matter integrity in adolescents with type 1 diabetes

Background

The notion that pediatric type 1 diabetes impacts brain function and structure early in life is of great concern. Neurological manifestations, including neurocognitive and behavioral symptoms, may be present from childhood, initially mild and undetectable in daily life. Despite intensive management and technological therapeutic interventions, most pediatric patients do not achieve glycemic control targets for HbA1c. One of the most common causes of such poor control and frequent transient hyperglycemic episodes may be lifestyle factors, including missed meal boluses.

Objective

The aim of this study was to assess the association between specific neurocognitive accomplishments-learning and memory, inhibition ability learning, and verbal and semantic memory-during meals with and without bolusing, correlated to diffusion tensor imaging measurements of major related tracts, and glycemic control in adolescents with type 1 diabetes compared with their healthy siblings of similar age.

Study design and methods

This is a case-control study of 12- to 18-year-old patients with type 1 diabetes (N = 17, 8 male patients, diabetes duration of 6.53 ± 4.1 years) and their healthy siblings (N = 13). All were hospitalized for 30 h for continuous glucose monitoring and repeated neurocognitive tests as a function of a missed or appropriate pre-meal bolus. This situation was mimicked by controlled, patient blinded manipulation of lunch pre-meal bolus administration to enable capillary glucose level of <180 mg/dl and to >240 mg/d 2 hours after similar meals, at a similar time. The diabetes team randomly and blindly manipulated post-lunch glucose levels by subcutaneous injection of either rapid-acting insulin or 0.9% NaCl solution before lunch. A specific neurocognitive test battery was performed twice, after each manipulation, and its results were compared, along with additional neurocognitive tasks administered during hospitalization without insulin manipulation. Participants underwent brain imaging, including diffusion tensor imaging and tractography.

Results

A significant association was demonstrated between glycemic control and performance in the domains of executive functions, inhibition ability, learning and verbal memory, and semantic memory. Inhibition ability was specifically related to food management. Poorer glycemic control (>8.3%) was associated with a slower reaction time.

Conclusion

These findings highlight the potential impairment of brain networks responsible for learning, memory, and controlled reactivity to food in adolescents with type 1 diabetes whose glycemic control is poor.

14. Children and Adolescents: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Diabetes and associated cognitive disorders: Role of the Hypothalamic-Pituitary Adrenal axis

Both diabetes types, types 1 and 2, are associated with cognitive impairments. Each period of life is concerned, and this is an increasing public health problem. Animal models have been developed to investigate the biological actors involved in such impairments. Many levels of the brain function (structure, volume, neurogenesis, neurotransmission, behavior) are involved. In this review, we detailed the part potentially played by the Hypothalamic-Pituitary Adrenal axis in these dysfunctions. Notably, regulating glucocorticoid levels, their receptors and their bioavailability appear to be relevant for future research studies, and treatment development.

Impact of glucose metabolism on the developing brain

Glucose is the most important substrate for proper brain functioning and development, with an increased glucose consumption in relation to the need of creating new brain structures and connections. Therefore, alterations in glucose homeostasis will inevitably be associated with changes in the development of the Nervous System. Several studies demonstrated how the alteration of glucose homeostasis - both hyper and hypoglycemia- may interfere with the development of brain structures and cognitivity, including deficits in intelligence quotient, anomalies in learning and memory, as well as differences in the executive functions. Importantly, differences in brain structure and functionality were found after a single episode of diabetic ketoacidosis suggesting the importance of glycemic control and stressing the need of screening programs for type 1 diabetes to protect children from this dramatic condition. The exciting progresses of the neuroimaging techniques such as diffusion tensor imaging, has helped to improve the understanding of the effects, outcomes and mechanisms underlying brain changes following dysglycemia, and will lead to more insights on the physio-pathological mechanisms and related neurological consequences about hyper and hypoglycemia.

14. Children and Adolescents: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Diagnosis and management of pediatric type 1 diabetes mellitus

Background: In contrast to type 2 diabetes, type 1 diabetes mellitus (T1DM) requires insulin treatment to control blood glucose. As the incidence and prevalence of T1DM have steadily increased; therefore, T1DM is increasingly being diagnosed not only in children and adolescents, but also in adults. Therefore, the importance of accurate diagnosis and optimal management of T1DM is being recognized in clinical practice.Current Concepts: T1DM is caused by insulin deficiency, following the destruction of insulin-producing pancreatic β-cells. Diagnosis of diabetes is based on the following criteria: fasting blood glucose levels ≥126 mg/dL, random blood glucose levels ≥200 mg/dL accompanied by symptoms of hyperglycemia, an abnormal 2-hour oral glucose tolerance test, or glycated hemoglobin ≥6.5%. Accurate diagnosis of T1DM based on patients’ clinical characteristics, serum C-peptide levels, and detection of autoantibodies against β-cell autoantigens is important for optimum care and to avoid complications. A target glycated hemoglobin level is recommended in children, adolescents, and young adults with access to comprehensive care. The availability of insulin analogues and mechanical technologies (insulin pumps and continuous glucose monitors) has improved the management of T1DM, and these are useful for the prevention of microvascular complications. Screening for microvascular complications should commence at puberty or 5 years after diagnosis of T1DM.Discussion and Conclusion: Effective cooperation and coordination between patient, parents, and healthcare providers are necessary to achieve a successful transition from pediatric to adult care in patients with T1DM. Diabetic management for T1DM should be individualized based on patients’ lifestyle, as well as psychosocial, and medical circumstances.

Poor glycaemic control is associated with increased risk of neurodevelopmental disorders in childhood-onset type 1 diabetes: a population-based cohort study

AIMS/HYPOTHESIS

The aim of this study was to investigate the effect of childhood-onset type 1 diabetes on the risk of subsequent neurodevelopmental disorders, and the role of glycaemic control in this association. We hypothesised that individuals with poor glycaemic control may be at a higher risk of neurodevelopmental disorders compared with the general population, as well as compared with individuals with type 1 diabetes with adequate glycaemic control.

METHODS

This Swedish population-based cohort study was conducted using data from health registers from 1973 to 2013. We identified 8430 patients with childhood-onset type 1 diabetes (diagnosed before age 18 years) with a median age of diabetes onset of 9.6 (IQR 5.9-12.9) and 84,300 reference individuals from the general population, matched for sex, birth year and birth county. Cox models were used to estimate the effect of HbA_1c on the risk of subsequent neurodevelopmental disorders, including attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorders (ASD) and intellectual disability.

RESULTS

During a median follow-up period of 5.6 years, 398 (4.7%) individuals with type 1 diabetes received a diagnosis of any neurodevelopmental disorder compared with 3066 (3.6%) in the general population, corresponding to an adjusted HR (HR_adjusted) of 1.31 (95% CI 1.18, 1.46) after additionally adjusting for other psychiatric morbidity prior to inclusion, parental psychiatric morbidity and parental highest education level. The risk of any neurodevelopmental disorder increased with HbA_1c levels and the highest risk was observed in patients with mean HbA_1c >8.6% (>70 mmol/mol) (HR_adjusted 1.90 [95% CI 1.51, 2.37]) compared with reference individuals without type 1 diabetes. In addition, when compared with patients with diabetes with HbA_1c <7.5% (<58 mmol/mol), patients with HbA_1c >8.6% (>70 mmol/mol) had the highest risk of any neurodevelopmental disorder (HR_adjusted 3.71 [95% CI 2.75, 5.02]) and of specific neurodevelopmental disorders including ADHD (HR_adjusted 4.16 [95% CI 2.92, 5.94]), ASD (HR_adjusted 2.84 [95% CI 1.52, 5.28]) and intellectual disability (HR_adjusted 3.93 [95% CI 1.38, 11.22]).

CONCLUSIONS/INTERPRETATION

Childhood-onset type 1 diabetes is associated with an increased risk of neurodevelopmental disorders, with the highest risk seen in individuals with poor glycaemic control. Routine neurodevelopmental follow-up visits should be considered in type 1 diabetes, especially in patients with poor glycaemic control.

Brain Health in Children with Type 1 Diabetes: Risk and Protective Factors

PURPOSE OF REVIEW

To synthesize findings from studies of neurocognitive complications in children with type 1 diabetes (T1D) and highlight potential risk and protective factors.

RECENT FINDINGS

Emerging evidence suggests that hyperglycemia and time in range may be more important for brain development than episodes of hypoglycemia. Further, diabetic ketoacidosis (DKA) at the time of T1D diagnosis appears to be a particular risk factor for neurocognitive complications, particularly deficits in executive function skills and memory, with differences in cerebral white matter microstructure seen via advanced magnetic resonance imaging methods, and lower scores on measures of attention and memory observed among children who were diagnosed in DKA. Other factors that may influence neurocognitive development include child sleep, caregiver distress, and diabetes device use, presumably due to improved glycemic control. We highlight neurocognitive risk and protective factors for children with T1D and priorities for future research in this high-risk population.

13. Children and Adolescents: Standards of Medical Care in Diabetes-2021

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Effects of Diabetic Ketoacidosis on Executive Function in Children With Type 1 Diabetes: Evidence From Wisconsin Card Sorting Test Performance

OBJECTIVE

Diabetic ketoacidosis (DKA) in patients with type 1 diabetes mellitus (T1DM) is known to affect memory function, but little is known about its impact on executive function. This study aimed to determine whether a history of DKA was associated with changes in executive function in children with T1DM.

METHODS

The sample consisted of 99 patients with T1DM with histories of DKA, 82 patients with T1DM without DKA, and 100 healthy controls aged 7 to 18 years. Neuropsychological function and emotion assessments were performed in all participants. The Wisconsin Card Sorting Test (WCST) was used to assess executive function.

RESULTS

Compared with healthy controls, the DKA group (but not the non-DKA group) had a significantly lower mean intelligence quotient (IQ; p = .006, Cohen d = 0.528) and a significantly higher rate of WCST perseverative errors (p = .006, Cohen d = 0.475). In the DKA group, the age at DKA onset was significantly associated with the IQ (p = .001) and the number of completed WCST categories (p = .046). Higher hemoglobin A1c levels were associated significantly with lower IQ (p < .001), increased rate of WCST perseverative errors (p = .015), and completion of fewer WCST categories (p = .027).

CONCLUSIONS

DKA has implications for executive function in children with T1DM. These findings emphasize the importance of DKA prevention in patients with known T1DM, especially younger children with newly diagnosed T1DM.

The cognitive and psychological effects of living with type 1 diabetes: a narrative review

Across the lifespan, type 1 diabetes mellitus has a profound (neuro)psychological impact. In young people, type 1 diabetes can interfere with psychosocial development and hamper school performance. In adulthood, it can interfere with work life, relationships and parenting. A substantial minority of adults with type 1 diabetes experience coping difficulties and high diabetes-related distress. In youth and adulthood, type 1 diabetes is related to mild cognitive decrements as well as affective disorders, such as depression and anxiety. There is limited literature available that explores the interaction between cognitive and psychological comorbidity and underlying mechanisms. The aims of the present narrative review were to summarize the current state of the literature regarding both cognitive and psychological comorbidities in type 1 diabetes across the lifespan, and to explore potential links between the two domains of interest to make suggestions for future research and clinical practice.

Type 1 diabetes mellitus management in young children: implementation of current technologies

The use of advanced technologies for diabetes management is on the rise among pediatric patients with type 1 diabetes (T1D). Continuous subcutaneous insulin infusion (CSII), continuous glucose monitoring, predictive low glucose suspend, hybrid closed-loop insulin delivery systems-all enable better diabetes management and glycemic control. However, when used by children, and especially very young children, specific aspects must be taken into consideration, including technical parameters, ease of use, parental stress, and satisfaction. The unique characteristics of T1D in children aged <6 years are reviewed and studies of the pros and cons of different technologies in this specific age group are presented. Addressing such issues when implementing advanced technologies among very young children with T1D will enable better diabetes management and will hopefully ease a tremendous burden of both children and families.

13. Children and Adolescents: Standards of Medical Care in Diabetes-2020

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Hypoglycaemia

In health hypoglycaemia is rare and occurs only in circumstances like extreme sports. Hypoglycaemia in type 1 Diabetes (T1D) and advanced type 2 Diabetes (T2D) are the result of interplay between absolute or relative insulin access and defective glucose counterregulation. The basic mechanism is, failure of decreasing insulin and failure of the compensatory increasing counterregulatory hormones at the background of falling blood glucose. Any person with Diabetes on anti-diabetic medication who behaves oddly in any way whatsoever is hypoglycaemic until proven otherwise. Hypoglycaemia can be a terrifying experience for a patient with Diabetes. By definition, hypoglycaemic symptoms are subjective and vary from person to person and even episode to episode in same person. Fear of iatrogenic hypoglycaemia is a major barrier in achieving optimum glycaemic control and quality of life which limits the reduction of diabetic complications. Diabetes patients with comorbidities especially with chronic renal failure, hepatic dysfunction, major limb amputation, terminal illness, cognitive dysfunction etc. are more vulnerable to hypoglycaemia. In most cases, prompt glucose intake reverts hypoglycaemia. Exogenous insulin in T1D and insulin treated advanced T2D have no control by pancreatic regulation. Moreover, failure of increase of glucagon and attenuated secretion in epinephrine causes the defective glucose counterregulation. In this comprehensive review, I will try to touch all related topics for better understanding of hypoglycaemia.

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.

Priming effect in children with Type 1 Diabetes Mellitus

Previous studies have evidenced cognitive difficulties across various domains in Type 1 Diabetes Mellitus (T1DM) children, but the implicit memory system has not yet been systematically explored.Taking into account that the interplay between memory and perception may be modulated by the semantic category of the stimuli and their salience, we explored explicit and implicit memory using both object and food stimuli to verify whether for T1DM children there is a feebleness in performing the function of memory as a function of the stimuli used.Eighteen T1DM children and 47 healthy children performed an explicit recognition task in which they were requested to judge whether the presented image had already been shown ("old") or not ("new") and an identification priming task in which they were asked to name new and old pictures presented at nine ascending levels of spatial filtering.Results did not reveal any differences between controls and T1DM children in the explicit memory recognition task, whereas some differences between the two groups were found in the identification priming task. In T1DM children, the priming effect was observed only for food images.The dissociation between implicit and explicit memory observed in children with diabetes seems to be modulated by the category of the stimuli, and these results underscore the relevance of taking into account this variable when exploring cognitive functions.

The effect of type 1 diabetes on the developing brain

The effect of type 1 diabetes on the developing brain is a topic of primary research interest. A variety of potential dysglycaemic insults to the brain can cause cellular and structural injury and lead to altered neuropsychological outcomes. These outcomes might be subtle in terms of cognition but appear to persist into adult life. Age and circumstance at diagnosis appear to play a substantial role in potential CNS injury. A history of diabetic ketoacidosis and chronic hyperglycaemia appear to be more injurious than previously suspected, whereas a history of severe hypoglycaemia is perhaps less injurious. Neurocognitive deficits manifest across multiple cognitive domains, including executive function and speed of information processing. Some evidence suggests that subtle brain injury might directly contribute to psychological and mental health outcomes. Impaired executive function and mental health, in turn, could affect patients' adherence and the ability to make adaptive lifestyle choices. Impaired executive functioning creates a potential feedback loop of diabetic dysglycaemia leading to brain injury, further impaired executive function and mental health, which results in suboptimal adherence, and further dysglycaemia. Clinicians dealing with patients with suboptimal glycaemic outcomes should be aware of these potential issues.

Association of attention deficit hyperactivity disorder with recurrent hypoglycemia in type 1 diabetes mellitus

OBJECTIVE

Data regarding the association between hypoglycemia and attention deficit hyperactivity disorder (ADHD) in children and adolescents with type 1 diabetes mellitus (T1DM) are limited. This study investigated whether hypoglycemia was associated with the risk of ADHD in young people with T1DM.

METHODS

Children and adolescents with a diagnosis of T1DM were identified from the Longitudinal National Health Insurance Database in Taiwan from 1998 to 2011. Among them who were newly diagnosed with hypoglycemia during 2000 to 2007 were selected for the hypoglycemia cohort. The hypoglycemia diagnosis date was defined as the index date. Those who were diagnosed with ADHD before the index date were excluded. The main outcome was the development of ADHD. In total, 726 participants with hypoglycemia and 2852 participants without hypoglycemia were included in this study.

RESULTS

The overall incidence density of ADHD was markedly increased among cohort with hypoglycemia compared with cohort without hypoglycemia (4.74 vs 1.65 per 1000 person-years), with an adjusted hazard ratio (aHR) of 2.73 (95% confidence interval [CI] = 1.50-4.98). Cohort with hypoglycemia who had experienced a hypoglycemic coma had a significantly higher risk of ADHD (aHR = 6.54, 95% CI = 1.89-22.7) compared with cohort without hypoglycemia.

CONCLUSIONS

Hypoglycemia, especially hypoglycemic coma, is significantly associated with a subsequent risk of ADHD in young people with T1DM.

13. Children and Adolescents: Standards of Medical Care in Diabetes-2019

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Glycemic control is related to cognitive dysfunction in Chinese children with type 1 diabetes mellitus

BACKGROUND

Type 1 diabetes mellitus (T1DM) is considered a risk factor for the development of cognitive difficulties. The present study examined whether the cognitive performance of Chinese children with T1DM differs from that of healthy control (HC) children, and whether cognitive dysfunction is related to glycemic control.

METHODS

Using a cross-sectional design, cognitive tests were administered, including general intelligence tests, to pediatric T1DM patients (n = 105) and HCs (n = 90). The effects of specific diabetes-related variables, including an earlier diabetes onset (<7 years of age), severe hypoglycemia, chronic hyperglycemia, and diabetic ketoacidosis (DKA), on cognitive outcomes were examined.

RESULTS

The T1DM group had lower IQ (P = 0.001) and attention (P = 0.018) scores than the HC group. Among T1DM patients, a younger age of diabetes onset was related to poorer performance on the visuospatial perception test (P = 0.017) and delayed logical memory (P = 0.012). Greater exposure to hyperglycemia over time was associated with lower visuospatial perception (P = 0.029), and DKA had a negative effect on the IQ score (P = 0.024). Compared with the late severe hypoglycemia subgroup, the early severe hypoglycemia subgroup (<7 years old) performed worse on both immediate (P = 0.001) and delayed (P = 0.049) visual memory tests.

CONCLUSIONS

Chinese children with T1DM showed deficits in IQ and attention. Earlier age of diabetes onset, chronic hyperglycemia, and DKA affected particular cognitive domains. Early exposure to severe hypoglycemia had negative effects on visual memory.

Shared pathological pathways of Alzheimer's disease with specific comorbidities: current perspectives and interventions

Alzheimer's disease (AD) belongs to one of the most multifactorial, complex and heterogeneous morbidity-leading disorders. Despite the extensive research in the field, AD pathogenesis is still at some extend obscure. Mechanisms linking AD with certain comorbidities, namely diabetes mellitus, obesity and dyslipidemia, are increasingly gaining importance, mainly because of their potential role in promoting AD development and exacerbation. Their exact cognitive impairment trajectories, however, remain to be fully elucidated. The current review aims to offer a clear and comprehensive description of the state-of-the-art approaches focused on generating in-depth knowledge regarding the overlapping pathology of AD and its concomitant ailments. Thorough understanding of associated alterations on a number of molecular, metabolic and hormonal pathways, will contribute to the further development of novel and integrated theranostics, as well as targeted interventions that may be beneficial for individuals with age-related cognitive decline.

12. Children and Adolescents: Standards of Medical Care in Diabetes-2018

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Regional Gray Matter Volumes as Related to Psychomotor Slowing in Adults with Type 1 Diabetes

OBJECTIVE

Psychomotor slowing is a common cognitive complication in type 1 diabetes (T1D), but its neuroanatomical correlates and risk factors are unclear. In nondiabetic adults, smaller gray matter volume (GMV) and presence of white matter hyperintensities are associated with psychomotor slowing. We hypothesize that smaller GMV in prefronto-parietal regions explains T1D-related psychomotor slowing. We also inspect the contribution of microvascular disease and hyperglycemia.

METHODS

GMV, white matter hyperintensities (WMH), and glucose levels were measured concurrently with a test of psychomotor speed (Digit Symbol Substitution Test [DSST]) in 95 adults with childhood-onset T1D (mean age/duration = 49/41 years) and 135 similarly aged non-T1D adults. Linear regression models tested associations between DSST and regional GMV, controlling for T1D, sex, and education; a bootstrapping method tested whether regional GMV explained between-group differences in DSST. For the T1D cohort, voxel-based and a priori regions-of-interest methods further tested associations between GMV and DSST, adjusting for WMH, hyperglycemia, and age.

RESULTS

Bilateral putamen, but no other regions examined, significantly attenuated DSST differences between the cohorts (bootstrapped unstandardized indirect effects: -3.49, -3.26; 95% confidence interval = -5.49 to -1.80, -5.29 to -1.44, left and right putamen, respectively). Among T1D, DSST was positively associated with GMV of bilateral putamen and left thalamus. Neither WMH, hyperglycemia, age, nor other factors substantially modified these relationships.

CONCLUSIONS

For middle-aged adults with T1D and cerebral microvascular disease, GMV of basal ganglia may play a critical role in regulating psychomotor speed, as measured via DSST. Studies to quantify the impact of basal ganglia atrophy concurrent with WMH progression on psychomotor slowing are warranted.

Chronic conditions in adolescents

The health problems related to the nervous system are on rise in young infants leading to high mortality amongst this age group. A chronic medical condition (CC) is present in this age group to the tune of 10–20%. We searched the electronic database PubMed for pre-clinical as well as clinical controlled trials reporting variable chronic conditions especially in pediatric patients. Most of these reports revealed that type 1 diabetes mellitus is the most common CC in young infants. In female patients, metabolic control is often disturbed during CC in this age group. Poor metabolism regulation often results in long-term complications, including cognitive disorders. In cognitive disorders, memory loss and learning problems are the most among adolescents. Executive problems are observed to be associated with low physical activities. The review article concludes that knowledge about factors influencing treatment adherence is crucial in chronically ill infants. Further, we should focus on protective factors in order to prevent health risk behavior.

Iowa Gambling Task Performance Prospectively Predicts Changes in Glycemic Control among Adolescents with Type 1 Diabetes

OBJECTIVES

Good glycemic control is an important goal of diabetes management. Late adolescents with type 1 diabetes (T1D) are at risk for poor glycemic control as they move into young adulthood. For a subset of these patients, this dysregulation is extreme, placing them at risk for life-threatening health complications and permanent cognitive declines. The present study examined whether deficiency in emotional decision making (as measured by the Iowa Gambling Task; IGT) among teens with T1D may represent a neurocognitive risk factor for subsequent glycemic dysregulation.

METHODS

As part of a larger longitudinal study, a total of 241 high-school seniors (147 females, 94 males) diagnosed with T1D underwent baseline assessment that included the IGT. Glycated hemoglobin (HbA1c), which reflects glycemic control over the course of the past 2 to 3 months, was also assessed at baseline. Of the 241,189 (127 females, 62 males, mean age=17.76, mean HbA1c=8.11) completed HbA1c measurement 1 year later.

RESULTS

Baseline IGT performance in the impaired range (per norms) was associated with greater dysregulation in glycemic control 1 year later, as evidenced by an average increase in HbA1c of 2%. Those with normal IGT scores (per norms) exhibited a more moderate increase in glycemic control, with an HbA1c increase of 0.7%. Several IGT scoring approaches were compared, showing that the total scores collapsed across all trials was most sensitive to change in glycemic control.

CONCLUSIONS

IGT assessment offers promise as a tool for identifying late adolescents at increased risk for glycemic dysregulation. (JINS, 2017, 23, 204-213).

Obesity and insulin resistance are associated with reduced activity in core memory regions of the brain

Increasing research in animals and humans suggests that obesity may be associated with learning and memory deficits, and in particular with reductions in episodic memory. Rodent models have implicated the hippocampus in obesity-related memory impairments, but the neural mechanisms underlying episodic memory deficits in obese humans remain undetermined. In the present study, lean and obese human participants were scanned using fMRI while completing a What-Where-When episodic memory test (the “Treasure-Hunt Task”) that assessed the ability to remember integrated item, spatial, and temporal details of previously encoded complex events. In lean participants, the Treasure-Hunt task elicited significant activity in regions of the brain known to be important for recollecting episodic memories, such as the hippocampus, angular gyrus, and dorsolateral prefrontal cortex. Both obesity and insulin resistance were associated with significantly reduced functional activity throughout the core recollection network. These findings indicate that obesity is associated with reduced functional activity in core brain areas supporting episodic memory and that insulin resistance may be a key player in this association.

•

Obesity associated with reduced activity in core recollection network during episodic memory.

•

Insulin resistance associated with reduced activity in core recollection network during episodic memory.

•

Insulin resistance, but not obesity, associated with poorer memory performance.

Metabolic control and academic achievement over time among adolescents with type 1 diabetes

The relation between metabolic control (HbA1c) and achievement (grade point average [GPA]) was examined over a period of 2.5 years (every 6 months) employing a dynamical systems approach that allowed for the examination of whether HbA1c was associated with change in subsequent GPA and vice versa. Metabolic control tends to deteriorate (i.e., with higher HbA1c reflecting poorer metabolic control) during adolescence. It was hypothesized that these higher levels of HbA1c would limit subsequent increases in GPA. The sample included 252 adolescents (Mbaseline age = 12.49 years, SD = 1.53; 53.6% female) with Type 1 diabetes. Mothers' report and school records provided information on relevant demographics and GPA; medical records provided values of HbA1c. Two simultaneous coupled change equations (i.e., examining current values in 1 variable associated with changes in the other) controlling relevant risk indicators (i.e., age, sex, disease duration, insulin delivery method, IQ) revealed higher levels of HbA1c limited increases in GPA. Higher levels of GPA, however, were not associated with change in HbA1c except for 2 instances where moderation existed by disease duration and IQ. Higher GPA was associated with slower increases in HbA1c over time for youth with shorter disease duration and lower IQ. These results affirm the importance of maintaining good metabolic control to facilitate adequate school performance across the adolescent years. Further, the results suggest that factors related to school achievement may protect adolescents who are newly diagnosed or who have low cognitive ability from subsequent deterioration in metabolic control. (PsycINFO Database Record

Cerebrovascular complications of diabetes: focus on cognitive dysfunction

The incidence of diabetes has more than doubled in the United States in the last 30 years and the global disease rate is projected to double by 2030. Cognitive impairment has been associated with diabetes, worsening quality of life in patients. The structural and functional interaction of neurons with the surrounding vasculature is critical for proper function of the central nervous system including domains involved in learning and memory. Thus, in this review we explore cognitive impairment in patients and experimental models, focusing on links to vascular dysfunction and structural changes. Lastly, we propose a role for the innate immunity-mediated inflammation in neurovascular changes in diabetes.

Cognitive disorders in diabetic patients

This chapter gives an overview of the literature on cognitive dysfunction in adults with type 1 or type 2 diabetes. First, methods to evaluate cognitive functioning and the pattern and severity of cognitive dysfunction in relation to diabetes will be discussed. The reader will note that diabetes is associated with worse cognitive functioning and an increased dementia risk. Next, diabetes-associated abnormalities on brain MRI, including reductions in brain volume - i.e., cerebral atrophy - and vascular lesions, will be addressed. At the group level there are clear relations between these imaging abnormalities and cognitive dysfunction, but at the level of the individual patient these relations are often less clear. Subsequently, risk factors for cognitive performance will be discussed. Evidently, these risk factors are related to diabetes type and the age of the patients involved. For type 1 diabetes, an early age at diabetes onset is the most consistent risk factor, whereas in type 2 diabetes, vascular risk factors and vascular comorbidities are consistent indicators of increased risk. The final section of the chapter addresses possible preventive and treatment measures and implications for daily care.

Diabetes and neurodegeneration in the brain

Although an association between diabetes mellitus (DM) and cognitive dysfunction has been recognized for a century, it is often not considered as a complication of DM and remains under-recognized. Cognitive dysfunction, usually present as mild cognitive impairment, can occur with either type 1 or type 2 DM. Both forms of DM contribute to accelerated cerebral atrophy and to the presence of heightened white matter abnormalities. These effects are noted most at the two extremes of life, in childhood and in the advanced years. The cognitive spheres most affected include attention and executive function, processing speed, perception, and memory. Although DM is unlikely to lead to frank dementia, its ability to exacerbate existing neurodegenerative processes, such as Alzheimer disease, will impact tremendously upon our society in the upcoming decades as our population ages. This chapter describes the clinical impact of DM upon the brain, along with discussion of the potential therapeutic avenues to be discovered in the coming decades. We need to prepare for better preventative and therapeutic management of this cerebral neurodegenerative condition.

Longitudinal Evaluation of Cognitive Functioning in Young Children with Type 1 Diabetes over 18 Months

OBJECTIVES

Decrements in cognitive function may already be evident in young children with type 1 diabetes (T1D). Here we report prospectively acquired cognitive results over 18 months in a large cohort of young children with and without T1D.

METHODS

A total of 144 children with T1D (mean HbA1c: 7.9%) and 70 age-matched healthy controls (mean age both groups 8.5 years; median diabetes duration 3.9 years; mean age of onset 4.1 years) underwent neuropsychological testing at baseline and after 18-months of follow-up. We hypothesized that group differences observed at baseline would be more pronounced after 18 months, particularly in those T1D patients with greatest exposure to glycemic extremes.

RESULTS

Cognitive domain scores did not differ between groups at the 18 month testing session and did not change differently between groups over the follow-up period. However, within the T1D group, a history of diabetic ketoacidosis (DKA) was correlated with lower Verbal IQ and greater hyperglycemia exposure (HbA1c area under the curve) was inversely correlated to executive functions test performance. In addition, those with a history of both types of exposure performed most poorly on measures of executive function.

CONCLUSIONS

The subtle cognitive differences between T1D children and nondiabetic controls observed at baseline were not observed 18 months later. Within the T1D group, as at baseline, relationships between cognition (Verbal IQ and executive functions) and glycemic variables (chronic hyperglycemia and DKA history) were evident. Continued longitudinal study of this T1D cohort and their carefully matched healthy comparison group is planned.