Flexible, intensive insulin therapy and dietary freedom in adolescents and young adults with Type 1 diabetes: a prospective implementation study

Increasing secular trends in height and obesity in children with type 1 diabetes: JSGIT cohort

BACKGROUND

Recently, anthropometric indices in children with type 1 diabetes mellitus (T1DM) have begun to change.

OBJECTIVE

To examine secular trends in patients' anthropometric indices.

SUBJECTS

Japanese children with T1DM from the 1995, 2000, 2008 and 2013 cohorts of The Japanese Study Group of Insulin Therapy for Childhood and Adolescent Diabetes.

METHODS

We analysed serum haemoglobin A1c (HbA1c) levels, the incidence of severe hypoglycaemic events, the types and doses of insulin, height standard deviation scores (SDS), body mass index (BMI) percentiles compared with healthy Japanese children and obesity prevalence over time. We also stratified the patients according to glycaemic control levels of <58 mmol/mol (optimal), 58-75 mmol/mol (suboptimal) and ≥75 mmol/mol (high-risk).

RESULTS

Data for 513-978 patients from each of the cohorts were analysed. The incidence of severe hypoglycaemic events decreased over time (from 21 to 4.8/100 patient-years), while the proportion of insulin analogue doses increased (14.6% to 98.6%). In addition, patient height SDS (-0.22 to +0.17), BMI percentile (52.1 to 58.7) and obesity prevalence (2.1% to 5.1%) increased. Height SDS increased in all of the glycaemic control subgroups, while BMI percentile and obesity prevalence increased in the suboptimal and high-risk groups.

CONCLUSIONS

Since 1995, the average height of children with T1DM has increased in parallel with increasing insulin doses. Clinicians should be aware of increased BMI in these patients and the associated risk of developing cardiovascular disease in the future.

What are the characteristics of the best type 1 diabetes patient education programmes (from diagnosis to long-term care), do they improve outcomes and what is required to make them more effective?

The last 20 years have witnessed a marked change in approaches to the management of type 1 diabetes in the UK. This is exemplified by National Institute of Health and Care Excellence (NICE) guidance which acknowledges that reaching and maintaining target glucose depends on people with type 1 diabetes effectively implementing flexible intensive insulin therapy. The guidance emphasizes that successful self-management requires the acquisition of complex skills and is best achieved by participation in high-quality structured education. Controlled trials and other research have shown that programmes teaching self-management can lower glucose levels while reducing hypoglycaemia, improve psychological outcomes and are highly cost-effective. An important principle of successful programmes is therapeutic education in which learning becomes a partnership between the professional and the person with diabetes who learns to fit diabetes into his/her everyday life. Other recommended elements of programmes include a written curriculum, group teaching by a professional multidisciplinary team and quality assurance. Yet many participants struggle post-course to implement and maintain skills, and overall HbA_1c levels, particularly in the UK, remain far from target. Recent studies have identified the barriers to sustained effective self-management and concluded that even high-quality programmes generally lack critical components. These include incorporating evidence from behaviour change research, exploiting the promise of new technologies in reducing the burden of self-management, and providing structured professional support once people have completed the training. Studies are currently underway to evaluate structured training courses which have added these elements and examine whether they can lower glucose to levels closer to target without impairing quality of life.

Self-management of sick days in young people with type 1 diabetes enhanced by phone support: A qualitative study

Aims and Objectives: The aim of this paper was to evaluate the impact of phone support on sick day management of young people with type 1 diabetes. Method: Qualitative exploratory study to understand the usage of a phone support service available, 8am to 8.30pm, seven days a week. Inclusion criteria were: (a) young people with type 1 diabetes who attend an age-specific service; (b) experienced acute diabetes crisis. Interviews were coded for themes using QSR NVivo™ Version 11 software. Findings were examined through the theoretical lens of the Health Belief Model. Results: Of 20 eligible individuals, 8 participated in the study. Five avoided emergency presentation by accessing the phone support service; three who did not were admitted for diabetic ketoacidosis. The interviews generated 3 major themes: (a) self-efficacy, (b) cues to action, (c) susceptibility. Conclusion: Enhancing self-efficacy and promoting confidence to seek help early during an acute health crisis enables young people to effectively self-manage and avoid hospitalization.

The prevalence of retinopathy in patients with type 1 diabetes treated with education-based intensified insulin therapy and its association with parameters of glucose control

AIM

Prevalence of retinopathy (DR) in patients with type 1 diabetes treated with education-based intensified insulin therapy (EBIIT) and its association with parameters of glucose control.

METHODS

151 patients with mean diabetes duration of 14.3 years [SD ± 5.8]) were analyzed. Eyes were examined using standardized 7 field ETDRS (Early Treatment Diabetic Retinopathy Study) settings and images analyzed by a professional external reading center. The glucose exposure over time was defined as HbA1c years, i.e. the sum of the differences between annual mean HbA1c (in %) minus the ideal HbA1c of 6.0% (42 mmol/mol) for each diabetes year (e.g. HbA1c of 8% (64 mmol/mol) over 6 years gives an excess HbA1c of 2.0% (22 for mmol/mol) for 6 years, resulting in 12 HbA1c years (or 131 for mmol/mol)).

RESULTS

The median (interquartile range) of individual mean HbA1c was 7.3% (6.8-7.8) [56 mmol/mol (51-62)]. and the median HbA1c years was 16.8 (9.1-29.1) [183 mmol/mol (99-319)]. No evidence for DR was found in 59 patients (39%), stage 1 DR in 43 (28.5%), stage 2 in 41 (27.2%), stage 3 in 7 (4.6%) and proliferative DR stage 4 in 1 patient. The best correlation between severity of DR and diabetes control measures was found for HbA1c years (Pearson r = 0.41, p < 0.001).

CONCLUSIONS

In type 1 diabetes EBIIT is associated with good diabetes control and a low prevalence of DR. The cumulative glucose exposure over time given as HbA1c years is the best predictor for development of DR. ClinicalTrials.gov Identifier: NCT02307110.

Health outcomes for youth with type 1 diabetes at 18 months and 30 months post transition from pediatric to adult care

AIMS

To identify (a) determinants of glycated haemoglobin (HbA1c) at 18 and 30 months following transition in young people with Type 1 diabetes mellitus (T1DM) to a youth-specific diabetes service; and to (b) evaluate the impact of the service on acute admissions with diabetic ketoacidosis (DKA) over a 14-year period.

METHODS

An audit of records of youth with T1DM referred from paediatric services to the multidisciplinary transition service at Westmead Hospital, from 2001 to 2012, and followed-up to 2014.

RESULTS

Data from 439 adolescents and young adults (Median age: 18) were analysed. The recommended standard of glycaemic control, HbA1c < 7.5% (58 mmol/mol), was achieved by 23% at baseline, 22% at 18-months, and 20% at 30-month. After adjusting for lag time (>3 months) and diabetes duration (>7 years), glycaemic control at first visit predicted subsequent glycaemic control at 18-month and 30-month follow-up. From 2001 to 2014, only 8.6% were lost to follow-up; admissions and readmissions for DKA reduced from 72% (32/47) to 4% (14/340) (p < 0.001). Furthermore, mean length of stay (LOS) significantly decreased from 6.56 to 2.36 days (p < 0.001).

CONCLUSIONS

Continuing engagement with the multidisciplinary transition service prevented deterioration in HbA1c following transition. Age-appropriate education and regular follow-up prevents DKA admissions and significantly reduced admission LOS.

A systematic review of interventions to improve outcomes for young adults with Type 1 diabetes

BACKGROUND

Many young adults with Type 1 diabetes experience poor outcomes. The aim of this systematic review was to synthesize the evidence regarding the effectiveness of interventions aimed at improving clinical, behavioural or psychosocial outcomes for young adults with Type 1 diabetes.

METHODS

Electronic databases were searched. Any intervention studies related to education, support, behaviour change or health service organizational change for young adults aged between 15-30 years with Type 1 diabetes were included. A narrative synthesis of all studies was undertaken due to the large degree of heterogeneity between studies.

RESULTS

Eighteen studies (of a possible 1700) were selected and categorized: Health Services Delivery (n = 4), Group Education and Peer Support (n = 6), Digital Platforms (n = 4) and Diabetes Devices (n = 4). Study designs included one randomized controlled trial, three retrospective studies, seven feasibility/acceptability studies and eight studies with a pre/post design. Continuity, support, education and tailoring of interventions to young adults were the most common themes across studies. HbA1c was the most frequently measured outcome, but only 5 of 12 studies that measured it showed a significant improvement.

CONCLUSION

Based on the heterogeneity among the studies, the effectiveness of interventions on clinical, behavioural and psychosocial outcomes among young adults is inconclusive. This review has highlighted a lack of high-quality, well-designed interventions, aimed at improving health outcomes for young adults with Type 1 diabetes.

Standards for Reporting Implementation Studies (StaRI): explanation and elaboration document

OBJECTIVES

Implementation studies are often poorly reported and indexed, reducing their potential to inform the provision of healthcare services. The Standards for Reporting Implementation Studies (StaRI) initiative aims to develop guidelines for transparent and accurate reporting of implementation studies.

METHODS

An international working group developed the StaRI guideline informed by a systematic literature review and e-Delphi prioritisation exercise. Following a face-to-face meeting, the checklist was developed iteratively by email discussion and critical review by international experts.

RESULTS

The 27 items of the checklist are applicable to the broad range of study designs employed in implementation science. A key concept is the dual strands, represented as 2 columns in the checklist, describing, on the one hand, the implementation strategy and, on the other, the clinical, healthcare or public health intervention being implemented. This explanation and elaboration document details each of the items, explains the rationale and provides examples of good reporting practice.

CONCLUSIONS

Previously published reporting statements have been instrumental in improving reporting standards; adoption by journals and authors may achieve a similar improvement in the reporting of implementation strategies that will facilitate translation of effective interventions into routine practice.

A rapid synthesis of the evidence on interventions supporting self-management for people with long-term conditions: PRISMS – Practical systematic RevIew of Self-Management Support for long-term conditions

Background

Despite robust evidence concerning self-management for some long-term conditions (LTCs), others lack research explicitly on self-management and, consequently, some patient groups may be overlooked.

Aim

To undertake a rapid, systematic overview of the evidence on self-management support for LTCs to inform health-care commissioners and providers about what works, for whom, and in what contexts.

Methods

Self-management is ‘the tasks . . . individuals must undertake to live with one or more chronic conditions . . . [including] . . . having the confidence to deal with medical management, role management and emotional management of their conditions’. We convened an expert workshop and identified characteristics of LTCs potentially of relevance to self-management and 14 diverse exemplar LTCs (stroke, asthma, type 2 diabetes mellitus, depression, chronic obstructive pulmonary disease, chronic kidney disease, dementia, epilepsy, hypertension, inflammatory arthropathies, irritable bowel syndrome, low back pain, progressive neurological disorders and type 1 diabetes mellitus). For each LTC we conducted systematic overviews of systematic reviews of randomised controlled trials (RCTs) of self-management support interventions (‘quantitative meta-reviews’); and systematic overviews of systematic reviews of qualitative studies of patients’ experiences relating to self-management (‘qualitative meta-reviews’). We also conducted an original systematic review of implementation studies of self-management support in the LTCs. We synthesised all our data considering the different characteristics of LTCs. In parallel, we developed a taxonomy of the potential components of self-management support.

Results

We included 30 qualitative systematic reviews (including 515 unique studies), 102 quantitative systematic reviews (including 969 RCTs), and 61 studies in the implementation systematic review. Effective self-management support interventions are multifaceted, should be tailored to the individual, their culture and beliefs, a specific LTC and position on the disease trajectory, and underpinned by a collaborative/communicative relationship between the patient and health-care professional (HCP) within the context of a health-care organisation that actively promotes self-management. Self-management support is a complex intervention and although many components were described and trialled in the studies no single component stood out as more important than any other. Core components include (1) provision of education about the LTC, recognising the importance of understanding patients’ pre-existing knowledge and beliefs about their LTC; (2) psychological strategies to support adjustment to life with a LTC; (3) strategies specifically to support adherence to treatments; (4) practical support tailored to the specific LTC, including support around activities of daily living for disabling conditions, action plans in conditions subject to marked exacerbations, intensive disease-specific training to enable self-management of specific clinical tasks; and (5) social support as appropriate. Implementation requires a whole-systems approach which intervenes at the level of the patient, the HCP and the organisation. The health-care organisation is responsible for providing the means (both training and time/material resources) to enable HCPs to implement, and patients to benefit from, self-management support, regularly evaluating self-management processes and clinical outcomes. More widely there is a societal need to address public understanding of LTCs. The lack of public story for many conditions impacted on patient help-seeking behaviour and public perceptions of need.

Conclusions

Supporting self-management is inseparable from the high-quality care for LTCs. Commissioners and health-care providers should promote a culture of actively supporting self-management as a normal, expected, monitored and rewarded aspect of care. Further research is needed to understand how health service managers and staff can achieve this culture change in their health-care organisations.

Study registration

This study is registered as PROSPERO CRD42012002898.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Patients' experiences of adjusting insulin doses when implementing flexible intensive insulin therapy: a longitudinal, qualitative investigation

AIM

To explore patients' experiences of using flexible intensive insulin therapy, a regimen requiring them to determine and adjust quick-acting and background/basal insulin doses and mealtime ratios.

METHODS

Repeat, in-depth interviews with 30 type 1 diabetes patients converted to flexible intensive insulin therapy recruited from Dose Adjustment for Normal Eating (DAFNE) courses in the UK.

RESULTS

While patients found determination of quick acting insulin doses relatively straightforward, many struggled, over time, to determine the correct mealtime ratios and adjust basal insulin doses independently. Reasons included: lack of confidence and poor analytical skills; deferential attitudes to health professionals; worries about hypoglycaemia; and, lack of record/diary keeping resulting in fixation on current readings and failure to spot patterns and problems. When health professional support was not sought and/or record keeping neglected, patients gradually developed over-reliance on corrective doses to attain blood glucose readings within target ranges.

CONCLUSION

While patients are motivated to use flexible intensive insulin therapy, they expressed a need for on-going health professional input, particularly to support adjustment of background insulin doses and mealtime ratios. The need to sustain diary/record keeping should be emphasised to patients and provision of a dedicated glycaemic support service is recommended.

Mobile phone support is associated with reduced ketoacidosis in young adults

AIMS

To determine if access to mobile phone support for sick-day management is associated with reduced hospital admissions with diabetic ketoacidosis in young adults aged 15-25 with Type 1 diabetes.

METHODS

This was an observational study with data collected prospectively from January 2005 to December 2008. A mobile phone support service for sick-day management began in May 2005. Data from clinic attendees (group 1), including age, sex, diabetes duration, referral age, insulin therapy delivery, clinic attendance and HbA(1c) , were compared with clinic attendees with diabetic ketosis accessing sick-day management phone support (group 2), clinic attendees not accessing phone support and admitted with diabetic ketoacidosis (group 3) and non-clinic attendees admitted with diabetic ketoacidosis (group 4).

RESULTS

Age was similar in all groups. Patients in group 3 had significantly shorter duration of diabetes (6.8 ± 3.1 years) than groups 1 or 2 (10.1 and 9.8 years, respectively). Diabetes control was poor in all presentations of diabetic ketoacidosis (groups 2-4, HbA(1c) > 97 mmol/mol, > 11%) and was significantly higher than clinic attendees without ketosis (HbA(1c) 70 mmol/mol, 8.6%; P < 0.001). There was similar attendance at the clinic across all three groups, 2.9 compared with 2.4 compared with 2.1 visits/year, respectively. Thirty-one patients accessed phone support on 83 occasions for sick-day management (mean 2.7 contacts/episode); two patients progressed to admission with diabetic ketoacidosis. Diabetic ketoacidosis admission rates in the clinic population fell significantly from baseline, 0.10 to 0.05 admissions per patient per year (P < 0.05) in the third year.

CONCLUSION

Mobile phone support is associated with reduced progression of ketosis to diabetic ketoacidosis in young adults despite poor diabetes control.

Potential of education-based insulin therapy for achievement of good metabolic control: a real-life experience

AIMS

Achievement of good metabolic control in Type 1 diabetes is a difficult task in routine diabetes care. Education-based flexible intensified insulin therapy has the potential to meet the therapeutic targets while limiting the risk for severe hypoglycaemia. We evaluated the metabolic control and the rate of severe hypoglycaemia in real-life clinical practice in a centre using flexible intensified insulin therapy as standard of care since 1990.

METHODS

Patients followed for Type 1 diabetes (n = 206) or those with other causes of absolute insulin deficiency (n = 17) in our outpatient clinic were analysed in a cross-sectional study. Mean age (± standard deviation) was 48.9 ± 15.7 years, with diabetes duration of 21.4 ± 14.4 years. Outcome measures were HbA(1c) and frequency of severe hypoglycaemia.

RESULTS

Median HbA(1c) was 7.1% (54 mmol/mol) [interquartile range 6.6-7.8 (51-62 mmol/mol)]; a good or acceptable metabolic control with HbA(1c) < 7.0% (53 mmol/mol) or 7.5% (58 mmol/mol) was reached in 43.5 and 64.6% of the patients, respectively. The frequency of severe hypoglycaemic episodes was 15 per 100 patient years: 72.3% of the patients did not experience any such episodes during the past 5 years.

CONCLUSIONS

Good or acceptable metabolic control is achievable in the majority of patients with Type 1 diabetes or other causes of absolute insulin deficiency in routine diabetes care while limiting the risk for severe hypoglycaemia.