DYNAMIC: Dynamic glucose management strategies delivered through a structured education program improves time in range in a socioeconomically deprived cohort of children and young people with type 1 diabetes with a history of hypoglycemia

The Utility of Smart Multiple Daily Injection Systems in Intensive Insulin-Treated People With Diabetes: An Italian Expert Consensus

BACKGROUND

Smart systems for multiple daily injections (Smart MDI) integrate continuous glucose monitoring, connected insulin pens, smartphone apps, and cloud-based data storage to provide bolus and corrective dose suggestions, reminders/alerts, automatic tracking and sharing of insulin therapy, and glycemic data to users, caregivers, and providers. This is an expert consensus on the clinical value of Smart MDI and critical points for implementation in adults and children/adolescents with diabetes.

METHODS

A nominal group technique combined with the estimate-talk-estimate approach was employed to achieve consensus among panel members from the Italian Intersociety Technology and Diabetes Study Group with expertise in pediatric and adult diabetes care.

RESULTS

The expert consensus indicated that glycemic profiles can be improved by using bolus dose suggestions based on glucose values, planned meals, the insulin-to-carbohydrate ratio, correction factors, and consideration of insulin-on-board. Automatic remote sharing of patient data on glycemia and insulin therapy allows clinicians to make more appropriate and timely therapeutic recommendations based on objective data. Dose tracking, bolus reminders/alerts, and reduced hypoglycemia and associated anxiety achieved through Smart MDI may improve adherence.

CONCLUSIONS

Smart MDI can reduce treatment burden while improving the daily experiences and glycemic outcomes for adults and children/adolescents with type 1 or type 2 diabetes. However, high-quality clinical data are lacking, and more evidence is needed to compare the effects of Smart MDI and other advanced insulin delivery systems on glycemic and patient-reported outcomes.

Ethnic disparities in HbA1c and hypoglycemia among youth with type 1 diabetes: beyond access to technology, social deprivation and mean blood glucose

INTRODUCTION

The UK national pediatric diabetes audit reports higher HbA1c for children and young people (CYP) with type 1 diabetes (T1D) of Black ethnicity compared with White counterparts. This is presumably related to higher mean blood glucose (MBG) due to lower socioeconomic status (SES) and less access to technology. We aimed to determine if HbA1c ethnic disparity persists after accounting for the above variables.

RESEARCH DESIGN AND METHODS

A retrospective analysis of participants who received structured education in continuous glucose monitoring (CGM) use was conducted at a tertiary center. HbA1c was paired with glucose metrics from 90-day CGM data. The influence of ethnicity, SES determined by Index of Multiple Deprivation (IMD), MBG and other covariates on HbA1c was evaluated using multiple variable regression analysis. Occurrence of hypoglycemia was evaluated.

RESULTS

A total of 168 (79 White, 61 South Asian, 28 Black) CYP with T1D were included. There were no differences between groups for age, MBG, time in range (3.9-10.0 mmol/L), diabetes duration, gender, insulin delivery method (multiple daily injections vs continuous subcutaneous insulin infusion), or percent sensor use (PSU). In multiple variable analysis, MBG (p<0.0001), ethnicity (p<0.0001), age (p<0.001), duration of diabetes (p<0.01) and PSU (p<0.05) accounted for 81% of the variability in HbA1c. Adjusted HbA1c in the Black group (67 mmol/mol) was higher than both South Asian (63 mmol/mol) and White groups (62 mmol/mol) (p<0.001). Despite significant IMD differences between groups, it did not influence HbA1c. Multiple variable analysis showed that the Black group experienced more hypoglycemia than South Asian and White groups (<3.9 and <3.0 mmol/L, p<0.05).

CONCLUSIONS

CYP from Black ethnic backgrounds have a higher HbA1c compared with their South Asian and White counterparts which is clinically significant and independent of MBG, potentially contributing to increased complications risk. Additionally, the Black group experienced a higher incidence of hypoglycemia, possibly due to a treat-to-HbA1c target approach.

Technology usage and glycaemic outcomes in a single tertiary centre with an ethnically diverse and socioeconomically deprived cohort of children with type 1 diabetes mellitus

Background

The UK National Paediatric Diabetes Audit (NPDA) data reports disparities in Haemoglobin A1c (HbA1c) levels among children and young people (CYP) with Type 1 Diabetes (T1D), with higher levels in those of Black ethnic background and lower socioeconomic status who have less access to technology. We investigate HbA1c differences in a T1D cohort with higher than national average technology uptake where > 60% come from an ethnic minority and/or socioeconomically deprived population.

Design & methods

Retrospective cross-sectional study investigating the influence of demographic factors, technology use, and socioeconomic status (SES) on glycaemic outcomes. The study population was 222 CYP with T1D who attended the diabetes clinic in 2022 at a single tertiary paediatric diabetes centre.

Results

Among 222 CYP, 60% were of ethnic minority (Asian, Black, Mixed and Other were 32%, 12%, 6% and 10% respectively) and 40% of white heritage. 94% used Continuous Glucose Monitoring (CGM) and 60% used Continuous Subcutaneous Insulin Infusion (CSII) via open or closed loop. 6% used Self-Monitoring of Blood Glucose (SMBG) and Multiple Daily Injections (MDI), 34% used CGM and MDI, 38% used CGM and CSII and 22% used Hybrid Closed-Loop (HCL) systems. Significant differences in HbA1c across therapy groups (p < 0.001) was noted with lowest HbA1c in HCL group (55 mmol/mol; p <0.001). Despite adjusting for therapy type, the Black group had higher HbA1c than their white and Asian counterparts (p<0.001). CYP from the most deprived tertile had significantly higher HbA1c levels (p < 0.001) but the difference was not sustained after adjusting for therapy type.

Conclusion

Advanced diabetes technologies improve glycaemic control. Whilst equalising technology access mitigates socioeconomic disparities in HbA1c, CYP from Black ethnic background continue to display a higher HbA1c. The study underscores the necessity of fair technology distribution and further research into elevated HbA1c levels among Black CYP using advanced diabetes technology.

Improved Glycemic Control in Insulin-Treated Individuals With Poorly Controlled Type 2 Diabetes Through Combined Structured Education With Real-Time Continuous Glucose Monitoring

BACKGROUND

We evaluated the efficacy of structured individualized education combined with real-time continuous glucose monitoring (rt-CGM, Dexcom G6) in improving glycemic outcomes in insulin-treated adults with poorly controlled type 2 diabetes (T2D).

METHODS

This multicenter, 16-week, single-arm study included 66 adults with T2D (multiple daily insulin [MDI]: 33; basal insulin: 33) with a ≥7.8%. Each cohort comprised 15 participants aged ≥60 years. The participants attended four educational sessions. The primary outcome was a change in glycated hemoglobin (HbA1c) levels between baseline and week 16.

RESULTS

Sixty-four individuals were included in this study, with a mean age of 58.3 ± 12.4 years. The mean HbA1c levels decreased from 9.0% at baseline to 7.1% at 16 weeks in the MDI group (difference: -1.8%, 95% confidence interval [CI] = -2.3 to -1.3) and from 8.8% to 7.0% in the basal insulin group (difference: -1.8%, 95% CI = -2.1 to -1.4). In the total population, the mean time in range 70 to 180 mg/dL increased by 25.2% (6 hours 4 minutes, 95% CI = 20.6 to 29.8), whereas the time in tight range 70 to 140 mg/dL increased by 17.3% (4 hours 10 minutes, 95% CI = 14.0 to 20.7). Both groups maintained a target of <1% of the time below the range of <54 mg/dL. Improvements in HbA1c and CGM metrics were comparable between individuals aged ≥60 years and those aged <60 years (all P-values for interaction >.1).

CONCLUSIONS

In adults with poorly controlled insulin-treated T2D, rt-CGM use with structured education significantly improved the HbA1c and CGM metrics, primarily by reducing hyperglycemia, regardless of age.

Continuous glucose monitoring with structured education in adults with type 2 diabetes managed by multiple daily insulin injections: a multicentre randomised controlled trial

AIMS/HYPOTHESIS

The aim of this study was to compare the effectiveness of stand-alone intermittently scanned continuous glucose monitoring (isCGM) with or without a structured education programme and blood glucose monitoring (BGM) in adults with type 2 diabetes on multiple daily insulin injections (MDI).

METHODS

In this 24 week randomised open-label multicentre trial, adults with type 2 diabetes on intensive insulin therapy with HbA1c levels of 58-108 mmol/mol (7.5-12.0%) were randomly assigned in a 1:1:1 ratio to isCGM with a structured education programme on adjusting insulin dose and timing according to graphical patterns in CGM (intervention group), isCGM with conventional education (control group 1) or BGM with conventional education (control group 2). Block randomisation was conducted by an independent statistician. Due to the nature of the intervention, blinding of participants and investigators was not possible. The primary outcome was change in HbA1c from baseline at 24 weeks, assessed using ANCOVA with the baseline value as a covariate.

RESULTS

A total of 159 individuals were randomised (n=53 for each group); 148 were included in the full analysis set, with 52 in the intervention group, 49 in control group 1 and 47 in control group 2. The mean (± SD) HbA1c level at baseline was 68.19±10.94 mmol/mol (8.39±1.00%). The least squares mean change (± SEM) from baseline HbA1c at 24 weeks was -10.96±1.35 mmol/mol (-1.00±0.12%) in the intervention group, -6.87±1.39 mmol/mol (-0.63±0.13%) in control group 1 (p=0.0367 vs intervention group) and -6.32±1.42 mmol/mol (-0.58±0.13%) in control group 2 (p=0.0193 vs intervention group). Adverse events occurred in 28.85% (15/52) of individuals in the intervention group, 26.42% (14/53) in control group 1 and 48.08% (25/52) in control group 2.

CONCLUSIONS/INTERPRETATION

Stand-alone isCGM offers a greater reduction in HbA1c in adults with type 2 diabetes on MDI when education on the interpretation of graphical patterns in CGM is provided.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04926623.

FUNDING

This study was supported by Daewoong Pharmaceutical Co., Ltd.

Enhancing equity in access to automated insulin delivery systems in an ethnically and socioeconomically diverse group of children with type 1 diabetes

INTRODUCTION

Manufacturer-supported didactic teaching programmes offer effective automated insulin delivery (AID) systems onboarding in children and young people (CYP) with type 1 diabetes (T1D). However, this approach has limited flexibility to accommodate the needs of families requiring additional support.

RESEARCH DESIGN AND METHODS

Evaluate the efficacy of an inperson manufacturer-supported didactic teaching programme (Group A), in comparison to a flexible flipped learning approach delivered virtually or inperson (Group B). Retrospective analysis of CYP with T1D using continuous glucose monitoring (CGM), who were initiated on AID systems between 2021 and 2023. Compare CGM metrics from baseline to 90 days for both groups A and B. Additionally, compare the two groups for change in CGM metrics over the 90-day period (∆), patient demographics and onboarding time.

RESULTS

Group A consisted of 74 CYP (53% male) with median age of 13.9 years and Group B 91 CYP (54% male) with median age of 12.7 years. From baseline to 90 days, Group A lowered mean (±SD) time above range (TAR, >10.0 mmol/L) from 47.6% (±15.0) to 33.2% (±15.0) (p<0.001), increased time in range (TIR, 3.9-10.0 mmol/L) from 50.4% (±14.0) to 64.7% (±10.2) (p<0.001). From baseline to 90 days, Group B lowered TAR from 51.3% (±15.1) to 34.5% (±11.3) (p<0.001) and increased TIR from 46.5% (±14.5) to 63.7% (±11.0) (p<0.001). There was no difference from baseline to 90 days for time below range (TBR, <3.9 mmol/L) for Group A and Group B. ∆ TAR, TIR and TBR for both groups were comparable. Group B consisted of CYP with higher socioeconomic deprivation, greater ethnic diversity and lower carer education achievement (p<0.05). The majority of Group B (n=79, 87%) chose virtual flipped learning, halving diabetes educator time and increasing onboarding cadence by fivefold.

CONCLUSIONS

A flexible virtual flipped learning programme increases onboarding cadence and capacity to offer equitable AID system onboarding.

A Systematic Review Supporting the Endocrine Society Guidelines: Management of Diabetes and High Risk of Hypoglycemia

CONTEXT

Interventions targeting hypoglycemia in people with diabetes are important for improving quality of life and reducing morbidity and mortality.

OBJECTIVE

To support development of the Endocrine Society Clinical Practice Guideline for management of individuals with diabetes at high risk for hypoglycemia.

METHODS

We searched several databases for studies addressing 10 questions provided by a guideline panel from the Endocrine Society. Meta-analysis was conducted when feasible. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess certainty of evidence.

RESULTS

We included 149 studies reporting on 43 344 patients. Continuous glucose monitoring (CGM) reduced episodes of severe hypoglycemia in patients with type 1 diabetes (T1D) and reduced the proportion of patients with hypoglycemia (blood glucose [BG] levels <54 mg/dL). There were no data on use of real-time CGM with algorithm-driven insulin pumps vs multiple daily injections with BG testing in people with T1D. CGM in outpatients with type 2 diabetes taking insulin and/or sulfonylureas reduced time spent with BG levels under 70 mg/dL. Initiation of CGM in hospitalized patients at high risk for hypoglycemia reduced episodes of hypoglycemia with BG levels lower than 54 mg/dL and time spent under 54 mg/dL. The proportion of patients with hypoglycemia with BG levels lower than 70 mg/dL and lower than 54 mg/dL detected by CGM was significantly higher than point-of-care BG testing. We found no data evaluating continuation of personal CGM in the hospital. Use of an inpatient computerized glycemic management program utilizing electronic health record data was associated with fewer patients with and episodes of hypoglycemia with BG levels lower than 70 mg/dL and fewer patients with severe hypoglycemia compared with standard care. Long-acting basal insulin analogs were associated with less hypoglycemia. Rapid-acting insulin analogs were associated with reduced severe hypoglycemia, though there were more patients with mild to moderate hypoglycemia. Structured diabetes education programs reduced episodes of severe hypoglycemia and time below 54 mg/dL in outpatients taking insulin. Glucagon formulations not requiring reconstitution were associated with longer times to recovery from hypoglycemia, although the proportion of patients who recovered completely from hypoglycemia was not different between the 2 groups.

CONCLUSION

This systematic review summarized the best available evidence about several interventions addressing hypoglycemia in people with diabetes. This evidence base will facilitate development of clinical practice guidelines by the Endocrine Society.

Advances in Continuous Glucose Monitoring and Integrated Devices for Management of Diabetes with Insulin-Based Therapy: Improvement in Glycemic Control

Continuous glucose monitoring (CGM) technology has evolved over the past decade with the integration of various devices including insulin pumps, connected insulin pens (CIPs), automated insulin delivery (AID) systems, and virtual platforms. CGM has shown consistent benefits in glycemic outcomes in type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) treated with insulin. Moreover, the combined effect of CGM and education have been shown to improve glycemic outcomes more than CGM alone. Now a CIP is the expected future technology that does not need to be worn all day like insulin pumps and helps to calculate insulin doses with a built-in bolus calculator. Although only a few clinical trials have assessed the effectiveness of CIPs, they consistently show benefits in glycemic outcomes by reducing missed doses of insulin and improving problematic adherence. AID systems and virtual platforms made it possible to achieve target glycosylated hemoglobin in diabetes while minimizing hypoglycemia, which has always been challenging in T1DM. Now fully automatic AID systems and tools for diabetes decisions based on artificial intelligence are in development. These advances in technology could reduce the burden associated with insulin treatment for diabetes.

An effective and cost-saving structured education program teaching dynamic glucose management strategies to a socio-economically deprived cohort with type 1 diabetes in a VIRTUAL setting

OBJECTIVES

Compare the clinical and cost-effectiveness of an established face to face (F2F) structured education program to a new remote (VIRTUAL) program teaching dynamic glucose management (DynamicGM) to children and young people with type 1 diabetes (CYPD) using continuous glucose monitoring (CGM). To ascertain the most effective DynamicGM strategies predicting time in range (TIR) (3.9-10.0 mmol/L) and incorporating these into a user-friendly teaching aid.

DESIGN AND METHODS

Effectiveness of the F2F and VIRTUAL programs were ascertained by comparing the mean change (Δ) from baseline to 6 months in HbA1c, TIR and severe hypoglycemia. Delivery cost for the two programs were evaluated. Factors predicting TIR in the combined cohort were determined and incorporated into a user-friendly infographic.

RESULTS

First 50 graduates per group were evaluated. The mean difference in Δ HbA1c, Δ TIR and Δ episodes of severe hypoglycemia between VIRTUAL and F2F groups were 1.16 (p = 0.47), 0.76 (p = 0.78) and -0.06 (p = 0.61) respectively. Delivery cost per 50 CYPD for VIRTUAL and F2F were $5752 and $7020, respectively. The strongest predictors of TIR (n = 100) were short bursts of exercise (10-40 min) to lower hyperglycemia (p < 0.001), using trend arrow adjustment tools (p < 0.001) and adjusting pre-meal bolus timing based on trend arrows (p < 0.01). These strategies were translated into a GAME (Stop highs), SET (Stay in target), MATCH (Prevent lows) mnemonic.

CONCLUSION

Teaching DynamicGM VIRTUALLY is just as effective as F2F delivery and cost saving. Short bursts of exercise and using CGM trend arrows to adjust insulin dose and timing improves TIR.

Effect of structured individualized education on continuous glucose monitoring use in poorly controlled patients with type 1 diabetes: A randomized controlled trial

AIM

We aimed to evaluate the efficacy of structured individualized education combined with real-time continuous glucose monitoring (rt-CGM) on glycemic outcomes in adults with type 1 diabetes.

METHODS

This was a single-center, 3-month, randomized controlled trial of 47 adults with type 1 diabetes with HbA1c ≥ 7.0% (53 mmol/mol). Study participants were assigned randomly (1:1) to a structured education group or control group. The control group received the same education as the intervention group in a 3-month extension study. The primary outcome was the mean difference in time in range (TIR 70-180 mg/dL [3.9-10.0 mmol/L]) between groups.

RESULTS

TIR was higher for the education group than the control group (63.4% vs. 44.5%), resulting in a between-group difference of 15.3% (95% CI 7.9 to 22.8, p < 0.001) at week 12. HbA1c decreased 0.5% (5.5 mmol/mol) more in the intervention group than the control group at week 12 (-0.1 to -1.0, p < 0.001). In the extension period, TIR increased significantly (8.9% [2.2 to 15.6], p = 0.01) in educated control group.

CONCLUSIONS

In adults with type 1 diabetes, rt-CGM use with individualized education resulted in better TIR than rt-CGM alone, highlighting the importance of personalized structured education when using rt-CGM. (ClinicalTrials.gov, number NCT03794934).

Glucose Management Indicator for People with Type 1 Asian Diabetes Is Different from That of the Published Equation: Differences by Glycated Hemoglobin Distribution

Background: We aimed to determine whether there are racial differences in glucose management indicator (GMI) equation for Asians and propose an adjusted GMI equation specific to Asians. Methods: This was a 24-week, prospective, observational study. A total of 106 Korean subjects with type 1 diabetes was included in the analyses. Continuous glucose monitoring (CGM: Dexcom G5) data and glycated hemoglobin (HbA1c) were obtained at the end of 3 months (n = 106) and 6 months (n = 70) of use of a CGM device. Full 3-month CGM data were collected from 176 patients. Results: Linear regression analysis between HbA1c and CGM-derived mean glucose (GMI [%] = 2.814 + 0.026 × mean glucose [mg/dL], R² = 0.739, P < 0.001) showed significant correlation. An increase corresponding to each 25 mg/dL increase of mean glucose was higher with the Asian-Dexcom-specific GMI (0.7%) than with the published GMI (0.6%). The mean Asian-Dexcom-specific GMI was significantly lower than the published GMI (P = 0.022), especially in patients with HbA1c <7.0% (<6.0%: P = 0.003, 6.0%-6.9%: P = 0.001). Conclusions: The GMI equation specific for Asian Type 1 diabetes was different from the published GMI equation. For a given CGM-derived mean glucose, GMI calculated with the published equation could overestimate HbA1c in Asian subjects with HbA1c <7.0%. Although race partially explains the differences in GMI equation between published and Asian data, future research with larger databases is needed to develop a specific formula for Asian populations.