Assessment of Adherence to Insulin Injections among Diabetic Patients on Basal-Bolus Regimen in Primary and Secondary Healthcare Centers in Al-Jouf Region of Saudi Arabia; A Descriptive Analysis

BACKGROUND

Patient adherence to insulin therapy is one of the major challenges during the treatment of diabetes mellitus. Considering the dearth of investigations, this study aimed to determine the adherence pattern and factors linked with nonadherence among diabetic patients using insulin in Al-Jouf region of Saudi Arabia.

METHODS

This cross-sectional study included diabetic patients using basal-bolus regimens, whether they had type 1 or type 2 diabetes. This study's objective was determined using a validated data collection form that included sections on demographics, reasons for missed insulin doses, list of barriers to therapy, difficulties during insulin administration, and factors that may improve insulin inaction adherence.

RESULTS

Of 415 diabetic patients, 169 (40.7%) were reported to forget doses of insulin every week. The majority of these patients (38.5%) forget one or two doses. Away from home (36,1%), inability to adhere to the diet (24.3%) and embarrassment to administer injections in public (23.7%) were frequently cited as reasons for missing insulin doses. The occurrence of hypoglycemia (31%), weight gain (26%), and needle phobia (22%) were frequently cited as obstacles to insulin injection use. Preparing injections (18.3%), using insulin at bedtime (18.3%), and storing insulin at a cold temperature (18.1%) were the most challenging aspects of insulin use for patients. Reduction in the number of injections (30.8%) and convenient timing for insulin administration (29.6%) were frequently cited as factors that may improve participant adherence.

CONCLUSIONS

This study revealed that the majority of diabetic patients forget to inject insulin, primarily as a result of travel. By identifying potential obstacles faced by patients, these findings direct health authorities to design and implement initiatives to increase insulin adherence among patients.

Patients' Preferences for Connected Insulin Pens: A Discrete Choice Experiment Among Patients with Type 1 and Type 2 Diabetes

BACKGROUND

This study quantified how people with diabetes value the unique features of connected insulin pens and related mobile apps, and the underlying reasons for preferring connected versus non-connected insulin pens.

METHODS

A discrete choice experiment (DCE) was conducted in the USA and UK to elicit preferences of adults (≥ 18 years) with type 1 or 2 diabetes for attributes of insulin pens. Attributes included device type, dosing support, glucose monitoring, additional app features, and data sharing. Relative attribute importance (RAI) scores were calculated to capture the relative importance of an attribute. Predicted choice probabilities were obtained to compare different profiles for connected and non-connected insulin pens.

RESULTS

The DCE was completed by 540 participants (58.9% male; 90.7% Caucasian; mean age, 58.3 years; 69.4% type 2 diabetes). Participants most valued the possibility of using a connected insulin pen with dosing support and automated dose logging (RAI = 39.9%), followed by automatic transfer of glucose levels (RAI = 29.0%), additional features of tracking diet and physical activity (RAI = 14.6%), data sharing (RAI = 13.6%), and device type (RAI = 2.9%). All profiles of connected insulin pens were preferred over a non-connected pen (p < 0.001), and pen profiles with advanced features were preferred over those without (p < 0.001). Preferences differed by age but not diabetes type, country of residence, or insulin regimen.

CONCLUSION

People with diabetes in the USA and UK prefer connected over non-connected insulin pens due largely to the availability of automated logging of dose and glucose levels.

A Deep Learning Framework for Automatic Meal Detection and Estimation in Artificial Pancreas Systems

Current artificial pancreas (AP) systems are hybrid closed-loop systems that require manual meal announcements to manage postprandial glucose control effectively. This poses a cognitive burden and challenge to users with T1D since this relies on frequent user engagement to maintain tight glucose control. In order to move towards fully automated closed-loop glucose control, we propose an algorithm based on a deep learning framework that performs multitask quantile regression, for both meal detection and carbohydrate estimation. Our proposed method is evaluated in silico on 10 adult subjects from the UVa/Padova simulator with a Bio-inspired Artificial Pancreas (BiAP) control algorithm over a 2 month period. Three different configurations of the AP are evaluated -BiAP without meal announcement (BiAP-NMA), BiAP with meal announcement (BiAP-MA), and BiAP with meal detection (BiAP-MD). We present results showing an improvement of BiAP-MD over BiAP-NMA, demonstrating 144.5 ± 6.8 mg/dL mean blood glucose level (-4.4 mg/dL, p< 0.01) and 77.8 ± 6.3% mean time between 70 and 180 mg/dL (+3.9%, p< 0.001). This improvement in control is realised without a significant increase in mean in hypoglycaemia (+0.1%, p= 0.4). In terms of detection of meals and snacks, the proposed method on average achieves 93% precision and 76% recall with a detection delay time of 38 ± 15 min (92% precision, 92% recall, and 37 min detection time for meals only). Furthermore, BiAP-MD handles hypoglycaemia better than BiAP-MA based on CVGA assessment with fewer control errors (10% vs. 20%). This study suggests that multitask quantile regression can improve the capability of AP systems for postprandial glucose control without increasing hypoglycaemia.

Missed and Mistimed Insulin Doses in People with Diabetes: A Systematic Literature Review

Background: Development of coordinated management approaches is important to facilitate self-care in people with diabetes (PwD). Gaining a better understanding of suboptimal insulin use is key in this endeavor. This review aimed, for the first time, to systematically identify and narratively summarize real-world evidence on the extent of suboptimal insulin use (missed and mistimed insulin) in PwD. Methods: A systematic literature search of MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews identified studies reporting on missed and mistimed insulin dosing. Results: From 3305 studies, 37 publications reporting on 30 unique studies that involved 58,617 PwD were included. Studies were conducted across 12 different countries and most employed cross-sectional surveys. Observations regarding missed and mistimed insulin doses were reported in 25 and 10 studies, respectively. PwD reported missing insulin doses, but rates varied due to differences in reporting methods, participant populations, and insulin regimens. The association between missed dosing and glycemic control was evaluated in ten studies in which the authors reported lower glycated hemoglobin (HbA1c) levels in PwD who did not omit insulin. The proportion of PwD reporting mistiming of insulin was in the range of 20-45%, depending on the study; this was associated with higher rates of hypoglycemia and higher HbA1c as reported by study authors. Reasons for suboptimal insulin use were multifactorial, occurring due to disrupted daily routines, social situations, and hypoglycemia avoidance. Conclusions: This review suggests that suboptimal insulin use is widespread and that PwD using insulin may still be struggling with disease management. There is an unmet need for better integrated support in managing the complexities of insulin therapy and for the development of systems (e.g. digital solutions) that empower people to take control of insulin-treated diabetes.

Interactive Nutrition Education Is More Effective in Terms of Improved Levels of Glycated Hemoglobin in Adolescent Patients with Poorly Controlled Type 1 Diabetes - A Randomized Study

INTRODUCTION

Effectively conducted nutrition education is one of the key elements of the therapy of type 1 diabetes. The aim of the study was to compare the effectiveness of two methods of nutrition education.

MATERIAL AND METHODS

A noninvasive interventional randomized single-blind study included 151 patients (13.7±2.2 years old) with poorly controlled type 1 diabetes, treated with the use of insulin pumps. The participants were randomly divided into two groups: a control group (C) in which informative education methods were used (a lecture) and an experimental group (E) in which interactive methods (quiz and multimedia application) were additionally applied. The concentration of glycated hemoglobin (HbA1c) was the primary outcome. The secondary outcomes were: standard deviation score-body mass index (SDS-BMI), standard deviation score-systolic blood pressure (SDS-SBP), standard deviation score-diastolic blood pressure (SDS-DBP), scores of Nutrition Knowledge Survey (NKS) and indices of healthy and unhealthy diet.

RESULTS

A marked reduction in HbA1c concentrations was observed after 3 months in group E [-0.47% (-0.77; -0.17), P<0.01; P=0.038 for the intergroup difference]. The positive effect was no longer present after 6 months. No significant changes regarding HbA1c were noted in group C at any stage of the study. After 6 months, both groups obtained better results in one part of NKS ("Blood glucose response to food"): group C [0.41 (0.15; 0.66), P<0.01], group E [0.80 (0.52; 1.08), P<0.001; P=0.042 for the intergroup difference]. No statistically significant differences between groups were noted as regards the remaining parameters.

CONCLUSION

Interactive nutrition education is more effective in terms of improved levels of HbA1c in children and adolescents with poorly controlled diabetes. However, an intensification of training frequency is recommended due to the transient effect of education.