Sleep and diabetes-specific psycho-behavioral outcomes of a new automated insulin delivery system in young children with type 1 diabetes and their parents

Psychosocial Aspects of Diabetes Technologies: Commentary on the Current Status of the Evidence and Suggestions for Future Directions

Diabetes technologies, including continuous glucose monitors, insulin pumps, and automated insulin delivery systems offer the possibility of improving glycemic outcomes, including reduced hemoglobin A1c, increased time in range, and reduced hypoglycemia. Given the rapid expansion in the use of diabetes technology over the past few years, and touted promise of these devices for improving both clinical and psychosocial outcomes, it is critically important to understand issues in technology adoption, equity in access, maintaining long-term usage, opportunities for expanded device benefit, and limitations of the existing evidence base. We provide a brief overview of the status of the literature-with a focus on psychosocial outcomes-and provide recommendations for future work and considerations in clinical applications. Despite the wealth of the existing literature exploring psychosocial outcomes, there is substantial room to expand our current knowledge base to more comprehensively address reasons for differential effects, with increased attention to issues of health equity and data harmonization around patient-reported outcomes.

Closed-Loop Therapy and Sleep in Young People Newly Diagnosed With T1D and Their Parents

BACKGROUND

A diagnosis of type 1 diabetes in a young person can create vulnerability for sleep. Historically it has been rare for young people to be offered a closed-loop system soon after diagnosis meaning that studies examining sleep under these circumstances in comparison with standard treatment have not been possible. In this study, we examine sleep in young people (and their parents) who were provided with hybrid closed-loop therapy at diagnosis of type 1 diabetes versus those who receive standard treatment over a 2-year period.

METHODS

The sample comprised 97 participants (mean age = 12.0 years; SD = 1.7) from a multicenter, open-label, randomized, parallel trial, where young people were randomized to either hybrid closed-loop insulin delivery or standard care at diagnosis. Sleep was measured using actigraphy and the Pittsburgh Sleep Quality Index (PSQI) in the young people, and using the PSQI in parents.

RESULTS

Sleep in young people using hybrid closed-loop insulin delivery did not differ significantly compared with those receiving standard care (although there were nonsignificant trends for better sleep in the closed-loop group for 4 of the 5 sleep actigraphy measures and PSQI). Similarly, there were nonsignificant differences for sleep between the groups at 24 months (with mixed direction of effects).

CONCLUSIONS

This study assessed for the first time sleep in young people using a closed-loop system soon after diagnosis. Although sleep was not significantly different for young people using closed-loop insulin delivery as compared with those receiving standard care, the direction of effects of the nonsignificant results indicates a possible tendency for better sleep quality in the hybrid closed-loop insulin delivery group at the beginning of the treatment.

Safety and Psychological Outcomes of Tandem t:Slim X2 Insulin Pump with Control-IQ Technology in Children, Adolescents, and Young Adults with Type 1 Diabetes: A Systematic Review

The Tandem t:slim X2 insulin pump is a second-generation automated insulin delivery system with Control-IQ technology. It consists of an X2 insulin pump, an integrated Dexcom sensor, and an embedded 'Control-IQ' algorithm, which predicts glucose levels 30 min in the future, adapting the programmed basal insulin rates to get glucose levels between 112.5 and 160 mg/dl (8.9 mmol/l). The system delivers automatic correction boluses of insulin when glucose levels are predicted to rise > 180 mg/dl (10 mmol/l). It has been commercially available since 2016. We reviewed the current evidence about the psychological, safety, and exercise-related outcomes of this device in children, adolescents, and young adults living with type 1 diabetes. We screened 552 papers, but only 21 manuscripts were included in this review. Fear of hypoglycemia is significantly reduced in young people with diabetes and their parents. Interestingly, diabetes-related distress is decreased; thus, the system is well accepted by the users. The sleeping quality of subjects living with diabetes and their caregivers is improved to a lesser extent as well. Despite the small number of data, this system is associated with a low rate of exercise-related hypoglycemia. Finally, evidence from the literature shows that this system is safe and effective in improving psychological personal outcomes. Even if further steps toward the fully closed loop are still mandatory, this second-generation automated insulin delivery system reduces the burden of diabetes. It properly addresses most psychological issues in children, adolescents, and young adults with type 1 diabetes mellitus; thus, it appears to be well accepted.

Effect of automated insulin delivery systems on person-reported outcomes in people with diabetes: a systematic review and meta-analysis

Background

Conclusive evidence on the benefits of automated insulin delivery (AID) systems on person-reported outcomes (PROs) is missing.

Methods

In this systematic review and meta-analysis, four databases (PubMed, PsycINFO, Cochrane, and GoogleScholar) were searched from inception up to August 7th, 2024. All types of studies were included if studies reported on PROs in people with diabetes using an AID system. All types of control groups in randomised controlled trials (RCT) were included. Summary data were extracted by three reviewers. Main outcomes focused on diabetes distress, fear of hypoglycaemia and quality of life. Meta-analyses were conducted for RCTs and observational studies separately. When five or more studies could be pooled, random-effects meta-analysis was used, otherwise common-effects meta-analysis was used. Risk of bias was evaluated with Cochrane tools. This study was registered with PROSPERO, CRD42022352502.

Findings

A total of 62 studies (n = 9253) were included reporting on 45 different questionnaires. Twenty-seven studies were RCTs and 25 were observational studies. RCT meta-analyses showed reduced diabetes distress (standardised mean difference [95% CI]: -0.159 [-0.309, -0.010], I2 = 23.0%), reduced fear of hypoglycaemia (-0.339 [-0.566, -0.111], I2 = 42.6%), and improved hypoglycaemia unawareness (-0.231 [-0.424, -0.037], I2 = 0.0%), quality of life in adults (0.347 [0.134, 0.560], I2 = 0.0%) and children/adolescents (0.249 [0.050, 0.448], I2 = 0.0%). Observational meta-analyses corroborated improvements in diabetes distress (-0.217 [-0.403, -0.031], I2 = 68.5%), fear of hypoglycaemia (-0.445 [-0.540, -0.349], I2 = 0.0%), hypoglycaemia unawareness (-0.212 [-0.419, -0.004], I2 = 0.0%), and showed improved sleep quality (-0.158 [-0.255, -0.061], I2 = 0.0%).

Interpretation

We found low to moderate effect sizes indicating that AID therapy is associated with reduced burden and improved well-being in people with diabetes. Evidence comes from both RCTs and observational studies. However, for some PROs only a limited number of studies could be pooled with a large heterogeneity in questionnaires used. More research is needed with a more uniformed assessment of PROs to demonstrate the added value of AID therapy on psychosocial outcomes.

Funding

None.

The psychosocial outcomes of advanced hybrid closed-loop system in children and adolescents with type 1 diabetes

The study was carried out to determine the psychosocial outcomes of advanced hybrid closed-loop (AHCL) systems in children and adolescents with type 1 diabetes (T1D). Single-center and cohort study with a duration 6 months consisted of 60 children and adolescents with T1D. Standard clinical procedures, including both glycemic indicators, e.g., sensor-measured time within the 70-180 mg/dL range and glycated hemoglobin (HbA1c) levels, and psychosocial metrics were used for data collection. The psychosocial metrics included the Pediatric Quality of Life Inventory (PedsQL) 3.0 Diabetes Module for both children (8-12 years) and parents; the Quality of Life for Youth scale for adolescents (13-18 years); the Strengths and Difficulties Questionnaire (SDQ); the Hypoglycemia Fear Survey for Children (HFS-C); the Revised Child Anxiety and Depression Scale (R-CADS); and AHCLS-specific DTSEQ satisfaction and expectation survey. These metrics were evaluated at the baseline and after 6 months of AHCL use. Of the 60 children and adolescents with T1D for whom the AHCL system was utilized, 41 of them, 23 female and 18 male, completed the surveys. The mean age of the 41 children and adolescents was 12.5 ± 3.2 (min. 6.7, max. 18) years. The time spent within the target glycemic range, i.e., time-in-range (TIR), improved from 76.9 ± 9% at the baseline to 80.4 ± 5% after 6 months of AHCL system use (p = 0.03). Additionally, HbA1c levels reduced from 7.1% ± 0.7% at the baseline to 6.8% ± 0.8% after 6 months of AHCL system use (p = 0.03). The most notable decline in HbA1c was observed in participants with higher baseline HbA1c levels. All patients' HFS-C and AHCL system-specific DTSEQ satisfaction and expectation survey scores were within the normal range at the baseline and remained unchanged during the follow-up period. No significant difference was found in the R-CADS scores of children and adolescents between baseline and after 6 months of AHCL system use. However, there was a significant decrease in the R-CADS scores of the parents. Patients' PedsQL scores were high both at the baseline and after 6 months. The SDQ scores were high at baseline, and there was no significant improvement at the end of 6 months.  Conclusion: This is the first study to investigate in detail the psychosocial outcomes of AHCL system use in T1D patients and their parents. Although state-of-the-art technologies such as AHCL provide patients with more flexibility in their daily lives and information about glucose fluctuations, the AHCL resulted in a TIR above the recommended target range without a change in QOL, HFS-C, SDQ, and R-CADS scores. The scores obtained from the R-CADS conducted by the parents of the children indicated that the use of pumps caused a psychological improvement in the long term, with a significant decrease in the R-CADS scores of the children and adolescents with T1D. What is Known: • Previous studies focused on clinical outcomes of AHCL systems in pediatric T1D patients, showing glycemic control improvements. • Limited attention given to psychosocial outcomes of AHCL systems in children and adolescents with T1D. • Crucial psychosocial factors like quality of life, emotional well-being, and fear of hypoglycemia underexplored in AHCL system context. What is New: • First study to comprehensively examine psychosocial outcomes of AHCL systems in pediatric T1D patients. • Study's robust methodology sets new standard for diabetes technology research and its impact on qualiy of life.

Glucometrics and device satisfaction in children and adolescents with type 1 diabetes using different treatment modalities: A multicenter real-world observational study

AIMS

To analyze metabolic outcomes, diabetes impact and device satisfaction in children and adolescents with type 1 diabetes in Italy who used different treatment modalities for diabetes care in a real-life context.

METHODS

In this multicenter, nationwide, cross-sectional study, 1464 participants were enrolled at a routine visit. The following treatment modalities were considered MDI + SMBG; MDI + CGM; Sensor Augmented Pump Therapy; predictive management of low glucose; Hybrid Closed Loop (HCL); Advanced Hybrid Closed Loop (AHCL). Health related quality of life was evaluated by the Italian version of the Diabetes Impact and Device Satisfaction Scale (DIDS) questionnaire.

RESULTS

Patients treated with AID systems were more likely to have HbA1c ≤ 6.5 %, higher percentage of time with glucose levels between 70 and 180 mg/dL, lower percentage of time with glucose levels above 180 mg/dL, higher device satisfaction, and reduced impact of diabetes. All the therapeutic modalities with respect to MDI + CGM, except for MDI + SMBG, contributed to increase the device satisfaction. HCL and AHCL respect to MDI + CGM were associated with lower diabetes impact.

CONCLUSION

Real-life use of automated insulin delivery systems is associated with reduced type 1 diabetes impact, increased device satisfaction, and achievement of glycemic goals.

Evidence from clinical trials on high-risk medical devices in children: a scoping review

BACKGROUND

Meeting increased regulatory requirements for clinical evaluation of medical devices marketed in Europe in accordance with the Medical Device Regulation (EU 2017/745) is challenging, particularly for high-risk devices used in children.

METHODS

Within the CORE-MD project, we performed a scoping review on evidence from clinical trials investigating high-risk paediatric medical devices used in paediatric cardiology, diabetology, orthopaedics and surgery, in patients aged 0-21 years. We searched Medline and Embase from 1st January 2017 to 9th November 2022.

RESULTS

From 1692 records screened, 99 trials were included. Most were multicentre studies performed in North America and Europe that mainly had evaluated medical devices from the specialty of diabetology. Most had enrolled adolescents and 39% of trials included both children and adults. Randomized controlled trials accounted for 38% of the sample. Other frequently used designs were before-after studies (21%) and crossover trials (20%). Included trials were mainly small, with a sample size <100 participants in 64% of the studies. Most frequently assessed outcomes were efficacy and effectiveness as well as safety.

CONCLUSION

Within the assessed sample, clinical trials on high-risk medical devices in children were of various designs, often lacked a concurrent control group, and recruited few infants and young children.

IMPACT

In the assessed sample, clinical trials on high-risk medical devices in children were mainly small, with variable study designs (often without concurrent control), and they mostly enrolled adolescents. We provide a systematic summary of methodologies applied in clinical trials of medical devices in the paediatric population, reflecting obstacles in this research area that make it challenging to conduct adequately powered randomized controlled trials. In view of changing European regulations and related concerns about shortages of high-risk medical devices for children, our findings may assist competent authorities in setting realistic requirements for the evidence level to support device conformity certification.

Psychosocial Impact of the Insulin-Only iLet Bionic Pancreas for Adults, Youth, and Caregivers of Youth with Type 1 Diabetes

Objective: To evaluate the psychosocial impact and user experience for the insulin-only configuration of iLet bionic pancreas (BP) in persons 6-83 years years of age with type 1 diabetes. Research Design and Methods: In this multicenter, randomized controlled, 13-week trial, 275 adults (221 randomly assigned to the BP group and 54 to the standard of care [SC] group) and 165 youth and their caregivers (112 randomly assigned to the BP group and 53 to the SC group) completed psychosocial questionnaires at baseline, mid-study, and the end of the trial. Results: In all age groups, most participants would recommend using the BP, including those with previous experience using automated insulin delivery devices. Similarly, the vast majority of participants reported a high level of perceived benefits and a low number of perceived burdens. Adult participants reported significant decreases in the fear of hypoglycemia and in diabetes-specific emotional distress, as well as improvements in their perceived well-being. Conclusion: Findings demonstrate acceptability, reduced burden, and positive psychosocial outcomes for adults. Children and teenagers also report high acceptability and reduced burden, but less clear improvements in psychosocial outcomes. Clinical Trial Registration Number: NCT04200313.

Frequency and Causes of Nocturnal Alarms in Youth and Young Adults With Type 1 Diabetes Using a First-Generation Hybrid Closed-Loop System

Background

Meeting glycemic recommendations is challenging for youth with type 1 diabetes. Diabetes technology, including continuous glucose monitoring (CGM) and hybrid closed-loop (HCL) automated insulin delivery systems, significantly increase achievement of glycemic targets; however, many youth struggle to sustain use of early HCL systems. Nocturnal alarm fatigue contributes to disrupted sleep and device discontinuation.

Methods

We examined the frequency and causes of nocturnal (10:00 p.m. to 6:00 a.m.) alarms in pediatric patients (N = 76, median age 14.5 years [interquartile range 11.8-17.0 years, range 7-24 years]) starting on a first-generation HCL system in a prospective observational study. Device data were analyzed with linear mixed-effects models to examine change across time at 3-month intervals for 12 months.

Results

At baseline (HCL system in nonautomated mode), participants averaged 3.3 ± 0.6 alarms per night. In the 2 weeks after starting HCL (automated) mode, alarm frequency significantly increased to 5.4 ± 0.5 times per night (P <0.001). Alarm frequency decreased through the remainder of the observational period; however, CGM sensor and HCL system use also declined. The types of alarms were evenly distributed among sensor maintenance, sensor threshold, pump, and HCL-specific alarms.

Conclusion

These data show that HCL system nocturnal alarms are frequent and may be barriers to sleep quality and device use. Further research is needed to assess the impact of diabetes technology on sleep and to determine method to improve sleep quality with technology use.

Measures of Patient-Reported Expectations, Acceptance, and Satisfaction Using Automated Insulin Delivery Systems: A Review

In people with type 1 diabetes, Automated Insulin Delivery (AID) systems adjust insulin delivery in response to sensor glucose data and consist of three components: an insulin pump, a continuous glucose sensor, and an algorithm that determines insulin delivery. To date, all the available AID systems require users to announce carbohydrate intake and deliver meal boluses, as well as respond to system alarms. The use of AID devices both initially and over time may be influenced by a variety of psychological factors. Analysis of patient-related outcomes should be taken into account, while recruiting applicants for the systems who are motivated and have realistic expectations in order to prevent AID dropout. We report an up-to-date summary of the available measures and semi-structured interview content to assess AID expectations, acceptance, and satisfaction using the AID systems. In conclusion, we suggest, before and after starting using AID systems, performing a specific evaluation of the related psychological implications, using validated measures and semi-structured interviews, that allows diabetes care providers to tailor their education approach to the factors that concern the patient at that time; they can teach problem-solving skills and other behavioral strategies to support sustained use of the AID system.

A Systematic Review of Commercial Hybrid Closed-Loop Automated Insulin Delivery Systems

INTRODUCTION

Several different forms of automated insulin delivery systems (AID systems) have recently been developed and are now licensed for type 1 diabetes (T1D). We undertook a systematic review of reported trials and real-world studies for commercial hybrid closed-loop (HCL) systems.

METHODS

Pivotal, phase III and real-world studies using commercial HCL systems that are currently approved for use in type 1 diabetes were reviewed with a devised protocol using the Medline database.

RESULTS

Fifty-nine studies were included in the systematic review (19 for 670G; 8 for 780G; 11 for Control-IQ; 14 for CamAPS FX; 4 for Diabeloop; and 3 for Omnipod 5). Twenty were real-world studies, and 39 were trials or sub-analyses. Twenty-three studies, including 17 additional studies, related to psychosocial outcomes and were analysed separately.

CONCLUSIONS

These studies highlighted that HCL systems improve time In range (TIR) and arouse minimal concerns around severe hypoglycaemia. HCL systems are an effective and safe option for improving diabetes care. Real-world comparisons between systems and their effects on psychological outcomes require further study.

Consensus Recommendations for the Use of Automated Insulin Delivery Technologies in Clinical Practice

The significant and growing global prevalence of diabetes continues to challenge people with diabetes (PwD), healthcare providers, and payers. While maintaining near-normal glucose levels has been shown to prevent or delay the progression of the long-term complications of diabetes, a significant proportion of PwD are not attaining their glycemic goals. During the past 6 years, we have seen tremendous advances in automated insulin delivery (AID) technologies. Numerous randomized controlled trials and real-world studies have shown that the use of AID systems is safe and effective in helping PwD achieve their long-term glycemic goals while reducing hypoglycemia risk. Thus, AID systems have recently become an integral part of diabetes management. However, recommendations for using AID systems in clinical settings have been lacking. Such guided recommendations are critical for AID success and acceptance. All clinicians working with PwD need to become familiar with the available systems in order to eliminate disparities in diabetes quality of care. This report provides much-needed guidance for clinicians who are interested in utilizing AIDs and presents a comprehensive listing of the evidence payers should consider when determining eligibility criteria for AID insurance coverage.

Sleep Habits of Early School-Aged Children with Type 1 Diabetes and Their Parents: Family Characteristics and Diabetes Management

STUDY OBJECTIVES

School-aged children with type 1 diabetes (T1D) and their parents are at risk for sleep disturbances, yet few studies have used objective measures to assess sleep characteristics in young children with T1D.

METHODS

Forty children (ages 5-9) with T1D and their parents wore actigraph watches and completed sleep diaries for 7 nights. Parents also completed questionnaires about demographic information, diabetes distress, fear of hypoglycemia, and family routines. Children's clinical data (HbA1c and blood glucose data) were extracted from the medical record.

RESULTS

Most of the children and their parents obtained insufficient sleep. Based on actigraphy data, children slept an average of 7.9 hours/night and parents slept 6.7 hours/night, below the recommendations of 9-11 and 7-9 hours of sleep, respectively. Shorter child sleep latency was significantly associated with better glycemic levels, and parents' sleep duration and efficiency were related to child's glycemic levels. Parental fear of hypoglycemia and lack of family routines were associated with poorer sleep quality in parents and children, and with parental diabetes distress.

CONCLUSIONS

Sleep duration and quality is a modifiable target for potentially improving glycemic levels and parental distress in early school-aged children with T1D.

Related factors associated with fear of hypoglycemia in parents of children and adolescents with type 1 diabetes - A systematic review

PROBLEM

Fear of hypoglycemia is a significant concern for parents of children/ adolescents with type 1 diabetes. Although some studies have explained the parental fear of hypoglycemia, the related factors were yet to be determined. This systematic review aims to identify the related factors of fear of hypoglycemia in the parents of children and adolescents with type 1 diabetes and provide a theoretical basis for further intervention.

ELIGIBILITY CRITERIA

PubMed, MEDLINE, EMBASE, Scopus, CINAHL, EBSCO, Web of Science, and Cochrane Library were systematically searched from 2010 to 2021. Studies evaluating the fear of hypoglycemia of parents and its associated factors were included.

SAMPLE

Twenty-three observational articles met the criteria.

RESULTS

Significant associations were found between fear of hypoglycemia and specific factors, including motherhood, nocturnal hypoglycemia, and the number of blood glucose monitoring. Psychological factors, including anxiety, depression, pediatric parenting stress, mindfulness, self-efficacy, quality of life, and sleep disorders, were conclusive and associations with parental fear of hypoglycemia.

CONCLUSIONS

Understanding parental fear of hypoglycemia can help parents prevent potential problems in diabetes management, thus promoting children's growth. According to current evidence, effective targeted interventions based on modifiable relevant factors can be developed to reduce the fear of hypoglycemia in parents while maintaining optimal blood glucose control in children/ adolescents.

IMPLICATIONS

Health professionals should pay more attention to the mental health of parents, and parents should be involved in the care plan and have the opportunity to discuss their fear of hypoglycemia in the most appropriate way to manage type 1 diabetes.

One-Year Real-World Study on Comparison among Different Continuous Subcutaneous Insulin Infusion Devices for the Management of Pediatric Patients with Type 1 Diabetes: The Supremacy of Hybrid Closed-Loop Systems

Since their advent in daily clinical practice, continuous subcutaneous insulin infusion (CSII) systems have been increasingly improved, leading to a high percentage of both adult and pediatric patients with diabetes now using insulin pumps. Different types of CSII systems are currently available, which are characterized by different settings and technical features. This longitudinal observational study aims to evaluate real-word glycemic outcomes in children and adolescents with type 1 diabetes using three different CSII devices: hybrid closed-loop (HCL) systems, predictive low glucose (PLGS) systems, and non-automated insulin pumps. The secondary objective was to identify clinical variables that may significantly influence the achievement of therapeutic goals in our study cohort. One-hundred-and-one patients on CSII therapy attending our pediatric diabetes center were enrolled. When compared with the non-automated group, patients using HCL systems showed higher levels of time in target glucose range (p = 0.003) and lower glucose variability (p = 0.008). Similarly, we found significantly better glucose metrics in HCL users in comparison to PLGS patients (time in range p = 0.008; coefficient of variation p = 0.009; time above 250 mg/dL p = 0.007). Multiple linear regression models showed that HCL systems (time in range p < 0.001) and high daily percentage of glycemic sensor use (time in range p = 0.031) are predictors for good glycemic control. The introduction and increasing availability of novel technologies for diabetes represent a promising strategy to improve glycemic control and quality of life in pediatric patients with type 1 diabetes. Our real-world data confirm the superiority of HCL systems in terms of improvement of time spent in the target glucose range, prevention of hypoglycemia, and reduction of glycemic variability.

Friend or Foe: a Narrative Review of the Impact of Diabetes Technology on Sleep

PURPOSE OF REVIEW

The purpose of this review is to present a review of sleep science, the relationship between sleep and type 1 diabetes, and highlight the current literature on sleep outcomes in adult and pediatric diabetes technology research.

RECENT FINDINGS

Sleep quality is associated with glycemic outcomes, diabetes self-management, and mental health in people with type 1 diabetes. Diabetes technologies, including insulin pumps, continuous glucose monitors, and hybrid closed-loop systems improve glycemic outcomes. However, many people find this technology challenging for a variety of reasons, including increased burden and frequent alarms, especially during the night. The impact of different devices on sleep quality and quantity has been mixed. The newest technology, the hybrid closed-loop systems, offers the best opportunity for nocturnal glycemic regulation and has improved patient and family perspectives on sleep quality. However, objective sleep assessment has not shown significant improvement on sleep duration. Sleep quality and quantity in people with type 1 diabetes are widely recognized as an important component of health care, and the literature regarding the impact of diabetes devices on sleep is increasing. However, sleep disruptions are common and a barrier to device use. Despite finding minimal changes to sleep duration with device use, subjective accounts of sleep quality are overall positive, especially in those using hybrid closed-loop systems. Sleep quantity and quality are important outcomes to consider as diabetes technology continues to evolve.

The Psychological Implications of Automated Insulin Delivery Systems in Type 1 Diabetes Care

Automated insulin delivery (AID) systems have brought important glycemic benefits to type 1 diabetes management. The present paper provides an overview of their psychological implications. Trials and real-world observational studies report improvements in diabetes-specific quality of life, with qualitative work describing reduced management burden, increased flexibility and improved relationships. Not all experiences are positive, however, evidenced by dropping algorithm use soon after device initiation. Apart from finance and logistics, reasons for discontinuation include technology frustrations, wear-related issues and unmet glycemic and work load expectations. New challenges include distrust in proper AID functioning, overreliance and deskilling, compensatory behaviors to override or trick the system and optimize time in range, and concerns related to wearing multiple devices on the body. Research efforts may focus on incorporating a diversity perspective, updating existing person-reported outcome measures according to new technology developments, addressing implicit or explicit health professional bias in technology access, examining the merits of incorporating stress reactivity in the AID algorithm, and developing concrete approaches for psychological counseling and support related to technology use. An open dialogue with health professionals and peers about expectations, preferences and needs may foster the collaboration between the person with diabetes and the AID system.

Improvements in Parental Sleep, Fear of Hypoglycemia, and Diabetes Distress With Use of an Advanced Hybrid Closed-Loop System

OBJECTIVE

Parental sleep quality may contribute to glycemic control in youth with type 1 diabetes. In this article we present sleep analysis from a multicenter, randomized trial of children ages 6-13 years with type 1 diabetes evaluating the Tandem Control-IQ (CIQ) hybrid closed-loop (HCL) system.

RESEARCH DESIGN AND METHODS

Pittsburgh Sleep Quality Index (PSQI) scores were assessed at baseline to identify parents as "poor" sleepers (PSQI >5). Glycemic and psycho-behavioral outcomes before and after CIQ use were analyzed in poor sleepers (n = 49) and their children.

RESULTS

Nocturnal time in range (P < 0.001) and time hyperglycemic (P < 0.001), Hypoglycemia Fear Survey for Parents score (P < 0.001), Problem Areas in Diabetes scale score (P < 0.001), PSQI score (P < 0.001), and Hypoglycemia Fear Survey for Children score (P = 0.025) significantly improved. Of poor sleepers, 27 became good sleepers (PSQI score <5).

CONCLUSIONS

Use of CIQ in youth with type 1 diabetes ages 6-13 years significantly improved sleep and psychosocial measures in parent poor sleepers, coinciding with improvements in child nocturnal glycemia, highlighting the relationship between HCL systems and parent sleep quality.

Emotional and Physical Health Impact in Children and Adolescents and their Caregivers Using Open-Source Automated Insulin Delivery: Qualitative Analysis of Lived Experiences. (Preprint)

Background

Given the limitations in the access and license status of commercially developed automated insulin delivery (AID) systems, open-source AID systems are becoming increasingly popular among people with diabetes, including children and adolescents.

Objective

This study aimed to investigate the lived experiences and physical and emotional health implications of children and their caregivers following the initiation of open-source AID, their perceived challenges, and sources of support, which have not been explored in the existing literature.

Methods

Data were collected through 2 sets of open-ended questions from a web-based multinational survey of 60 families from 16 countries. The narratives were thematically analyzed, and a coding framework was identified through iterative alignment.

Results

A range of emotions and improvements in quality of life and physical health were reported, as open-source AID enabled families to shift their focus away from diabetes therapy. Caregivers were less worried about hypoglycemia at night and outside their family homes, leading to increased autonomy for the child. Simultaneously, the glycemic outcomes and sleep quality of both the children and caregivers improved. Nonetheless, the acquisition of suitable hardware and technical setup could be challenging. The #WeAreNotWaiting community was the primary source of practical and emotional support.

Conclusions

Our findings show the benefits and transformative impact of open-source AID and peer support on children with diabetes and their caregivers and families, where commercial AID systems are not available or suitable. Further efforts are required to improve the effectiveness and usability and facilitate access for children with diabetes, worldwide, to benefit from this innovative treatment.

International Registered Report Identifier (IRRID)

RR2-10.2196/15368

The automated pancreas: A review of technologies and clinical practice

Insulin pumps and glucose sensors are effective in improving diabetes therapy and reducing acute complications. The combination of both devices using an algorithm-driven interoperable controller makes automated insulin delivery (AID) systems possible. Many AID systems have been tested in clinical trials and have proven safety and effectiveness. However, currently, none of these systems are available for routine use in children younger than 6 years in Europe. For continued use, both users and prescribers must have sound knowledge of the features of the individual AID systems. Presently, all systems require various user interactions (e.g. meal announcements) because fully automated systems are not yet developed. Open-source systems are non-regulated variants to circumvent existing regulatory conditions. There are risks here for both users and prescribers. To evaluate AID therapy, the metric data of the glucose sensors, 'time in target range' and 'glucose management index', are novel recognized and suitable parameters allowing a consultation based on real glucose and insulin pump download data from the daily life of people with diabetes. Read out via cloud-based software or automatic download of such individual treatment data provides the ideal technical basis for shared decision-making through telemedicine, which must be further evaluated for general use.

Type 1 Diabetes, Sleep, and Hypoglycemia

PURPOSE OF REVIEW

To review the relationship between sleep and hypoglycemia, sleep characteristics, and their associations with glycemic control in persons with type 1 diabetes (T1D). The effects of sleep interventions and diabetes technology on sleep are summarized.

RECENT FINDINGS

Nocturnal hypoglycemia affects objective and subjective sleep quality and is related to behavioral, psychological, and physiological factors. Sleep disturbances are common, including inadequate sleep, impaired sleep efficiency, poor subjective satisfaction, irregular timing, increased daytime sleepiness, and sleep apnea. Some have a bidirectional relationship with glycemic control. Preliminary evidence supports sleep interventions (e.g., sleep extension and sleep coach) in improving sleep and glycemic control, while diabetes technology use could potentially improve sleep. Hypoglycemia and sleep disturbances are common among persons with T1D. There is a need to develop sleep promotion programs and test their effects on sleep, glucose, and related outcomes (e.g., self-care, psychological health).

Long-term Occupational Consequences for Families of Children With Type 1 Diabetes: The Mothers Take the Burden

OBJECTIVE

To investigate the occupational and financial consequences for parents following the onset of type 1 diabetes in their child.

RESEARCH DESIGN AND METHODS

A questionnaire assessing occupational and financial situations before and in the first year after the onset of diabetes was distributed to all families with a child ≤14 years of age at diagnosis with a diabetes duration of at least 12 months in nine German pediatric diabetes centers.

RESULTS

Data of 1,144 children (mean age at diagnosis 6.7 [3.6] years; 46.5% female) and their families were obtained. Mothers' occupational status reflected in paid working hours was significantly reduced in the first year after their child's diabetes diagnosis (P < 0.001). Overall, 15.1% of mothers stopped working, and 11.5% reduced working hours. Mothers of preschool children were particularly affected. Fathers' working status hardly changed (P = 0.75). Nearly half of the families (46.4%) reported moderate to severe financial losses. Compared with an earlier similar study in 2003, significant negative occupational consequences for mothers and financial burden on families remained unchanged in 2018 (P = 0.59 and 0.31, respectively).

CONCLUSIONS

Mothers of young children with newly diagnosed diabetes experienced negative consequences in their occupational situation. This inequality for mothers can have long-term negative consequences for their mental health and future economic situation. There is an urgent need for action to reduce the burden on families and to provide professional, social, and regulatory support, especially for mothers of young children with diabetes.

Psychometric Properties of the Hypoglycemia Fear Survey in a Clinical Sample of Adolescents with Type 1 Diabetes and Their Caregivers

OBJECTIVE

A previously published exploratory factor analysis suggested that the Hypoglycemia Fear Survey-Child and Parent Versions, is comprised of three subscales: Maintain High Blood Glucose, Helplessness/Worry About Low Blood Glucose, and Worry About Negative Social Consequences. The primary aim of this study was to confirm this three-factor model with a clinical population of adolescents with type 1 diabetes (T1D) and their caregivers.

METHODS

Participants included N = 1,035 youth ages 10-17.99 years with T1D, and their female (N = 835) and/or male (N = 326) caregivers who completed the Hypoglycemia Fear Survey independently during a routine medical appointment. We conducted confirmatory factor analysis and examined reliability of the Hypoglycemia Fear Survey and its associations with demographics and clinical outcomes (e.g., mean blood glucose, glycemic control).

RESULTS

Confirmatory factor analysis supported the three-factor model in youth and female and male caregivers. The internal consistencies for Maintain High Blood Glucose, Helplessness/Worry About Low Blood Glucose, and Worry About Negative Social Consequences were acceptable. The majority of demographic and clinical outcome variables correlated as hypothesized with the three subscales.

CONCLUSIONS

Using a large clinical sample of adolescents with T1D and their caretakers, we confirmed the three-factor model for the Hypoglycemia Fear Survey, which is sufficiently reliable to be used in a clinical setting. Important areas of future research include examining moderators for the effect of fear of hypoglycemia on clinical outcomes, and possible inclusion of items related to modern diabetes devices.