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Jacobsen LM, Sherr JL, Considine E, Chen A, Peeling SM, Hulsmans M, Charleer S, Urazbayeva M, Tosur M, Alamarie S, Redondo MJ, Hood KK, Gottlieb PA, Gillard P, Wong JJ, Hirsch IB, Pratley RE, Laffel LM, Mathieu C. Utility and precision evidence of technology in the treatment of type 1 diabetes: a systematic review. COMMUNICATIONS MEDICINE 2023; 3:132. [PMID: 37794113 PMCID: PMC10550996 DOI: 10.1038/s43856-023-00358-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 09/15/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND The greatest change in the treatment of people living with type 1 diabetes in the last decade has been the explosion of technology assisting in all aspects of diabetes therapy, from glucose monitoring to insulin delivery and decision making. As such, the aim of our systematic review was to assess the utility of these technologies as well as identify any precision medicine-directed findings to personalize care. METHODS Screening of 835 peer-reviewed articles was followed by systematic review of 70 of them (focusing on randomized trials and extension studies with ≥50 participants from the past 10 years). RESULTS We find that novel technologies, ranging from continuous glucose monitoring systems, insulin pumps and decision support tools to the most advanced hybrid closed loop systems, improve important measures like HbA1c, time in range, and glycemic variability, while reducing hypoglycemia risk. Several studies included person-reported outcomes, allowing assessment of the burden or benefit of the technology in the lives of those with type 1 diabetes, demonstrating positive results or, at a minimum, no increase in self-care burden compared with standard care. Important limitations of the trials to date are their small size, the scarcity of pre-planned or powered analyses in sub-populations such as children, racial/ethnic minorities, people with advanced complications, and variations in baseline glycemic levels. In addition, confounders including education with device initiation, concomitant behavioral modifications, and frequent contact with the healthcare team are rarely described in enough detail to assess their impact. CONCLUSIONS Our review highlights the potential of technology in the treatment of people living with type 1 diabetes and provides suggestions for optimization of outcomes and areas of further study for precision medicine-directed technology use in type 1 diabetes.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Mustafa Tosur
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
- Children's Nutrition Research Center, USDA/ARS, Houston, TX, USA
| | - Selma Alamarie
- Stanford University School of Medicine, Stanford, CA, USA
| | - Maria J Redondo
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Korey K Hood
- Stanford University School of Medicine, Stanford, CA, USA
| | - Peter A Gottlieb
- Barbara Davis Center, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Jessie J Wong
- Children's Nutrition Research Center, USDA/ARS, Houston, TX, USA
| | - Irl B Hirsch
- University of Washington School of Medicine, Seattle, WA, USA
| | | | - Lori M Laffel
- Joslin Diabetes Center, Harvard Medical School, Boston, MA, USA
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Kamiński M, Gawrecki A, Araszkiewicz A, Szadkowska A, Skowrońska B, Stankiewicz W, Michalak A, Cieluch A, Dżygało K, Seget S, Biegański G, Adamska A, Ksiądz K, Szymańska-Garbacz E, Flotyńska J, Zozulinska-Ziolkiewicz D. Nighttime Hypoglycemia in Children with Type 1 Diabetes after one Day of Football Tournament. Int J Sports Med 2020; 41:972-980. [PMID: 32634846 DOI: 10.1055/a-1192-5992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The aim of the study was to investigate factors related to the occurrence of nighttime hypoglycemia after a football tournament in children with type 1 diabetes mellitus. The multicenter study (GoalDiab study) included 189 children and adolescents with type 1 diabetes mellitus, from 11 diabetes care centers in Poland. Hypoglycemia was defined according to the International Hypoglycemia Study Group Statement. We analyzed the data of 95 participants with completed protocols with regards to nighttime hypoglycemia (82% male), aged 11.6 (9.8-14.2) years, diabetes duration 5.0 (2.0-8.0) years. There were 47 episodes of nighttime Level 1 hypoglycemia (≤3.9 mmol/L). Occurrence of clinically important Level 2 hypoglycemia (<3.0 mmol/L) during a game period was positively associated with nighttime hypoglycemia (≤3.9 mmol/L) incident (Odds Ratio=10.7; 95% Confidence Interval: 1.1-100.2; p=0.04). Using Continuous Glucose Monitoring was negatively associated with the occurrence of nighttime hypoglycemia (≤3.9 mmol/L) compared with using glucose meters or Flash Glucose Monitoring (Odds Ratio=0.31; 95% Confidence Interval: 0.12-0.83; p=0.02). The occurrence of clinically important hypoglycemia related to physical activity is associated with the occurrence of hypoglycemia during the night. Continuous Glucose Monitoring is negatively associated with nighttime hypoglycemia after a day of competition.
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Affiliation(s)
- Mikołaj Kamiński
- Department of Internal Medicine and Diabetology, Poznan University of Medical Sciences, Poznan, Poland
| | - Andrzej Gawrecki
- Department of Internal Medicine and Diabetology, Poznan University of Medical Sciences, Poznan, Poland
| | - Aleksandra Araszkiewicz
- Department of Internal Medicine and Diabetology, Poznan University of Medical Sciences, Poznan, Poland
| | - Agnieszka Szadkowska
- Department of Pediatrics, Diabetology, Endocrinology and Nephrology, Medical University of Lodz, Lodz, Poland
| | - Bogda Skowrońska
- Department of Pediatric Diabetes and Obesity, Poznan University of Medical Sciences, Poznan, Poland
| | - Witold Stankiewicz
- Department of Pediatric Diabetes and Obesity, Poznan University of Medical Sciences, Poznan, Poland
| | - Arkadiusz Michalak
- Department of Pediatrics, Diabetology, Endocrinology and Nephrology, Medical University of Lodz, Lodz, Poland
| | - Aleksandra Cieluch
- Department of Internal Medicine and Diabetology, Poznan University of Medical Sciences, Poznan, Poland
| | - Katarzyna Dżygało
- Department of Pediatrics, Medical University of Warsaw, Warszawa, Poland
| | - Sebastian Seget
- Department of Children's Diabetology, Medical University of Silesia, Katowice, Poland
| | - Grzegorz Biegański
- Department of Infectious Diseases and Child Neurology, Poznan University of Medical Sciences, Poznan, Poland
| | - Anna Adamska
- Department of Internal Medicine and Diabetology, Poznan University of Medical Sciences, Poznan, Poland
| | - Katarzyna Ksiądz
- Department of Internal Medicine and Diabetology, Poznan University of Medical Sciences, Poznan, Poland
| | | | - Justyna Flotyńska
- Department of Internal Medicine and Diabetology, Poznan University of Medical Sciences, Poznan, Poland
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Calhoun P, Levine RA, Fan J. Repeated measures random forests (RMRF): Identifying factors associated with nocturnal hypoglycemia. Biometrics 2020; 77:343-351. [PMID: 32311079 DOI: 10.1111/biom.13284] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Revised: 04/04/2020] [Accepted: 04/07/2020] [Indexed: 12/19/2022]
Abstract
Nocturnal hypoglycemia is a common phenomenon among patients with diabetes and can lead to a broad range of adverse events and complications. Identifying factors associated with hypoglycemia can improve glucose control and patient care. We propose a repeated measures random forest (RMRF) algorithm that can handle nonlinear relationships and interactions and the correlated responses from patients evaluated over several nights. Simulation results show that our proposed algorithm captures the informative variable more often than naïvely assuming independence. RMRF also outperforms standard random forest and extremely randomized trees algorithms. We demonstrate scenarios where RMRF attains greater prediction accuracy than generalized linear models. We apply the RMRF algorithm to analyze a diabetes study with 2524 nights from 127 patients with type 1 diabetes. We find that nocturnal hypoglycemia is associated with HbA1c, bedtime blood glucose (BG), insulin on board, time system activated, exercise intensity, and daytime hypoglycemia. The RMRF can accurately classify nights at high risk of nocturnal hypoglycemia.
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Affiliation(s)
| | - Richard A Levine
- Department of Mathematics and Statistics, Analytic Studies and Institutional Research, San Diego State University, San Diego, California
| | - Juanjuan Fan
- Department of Mathematics and Statistics, San Diego State University, San Diego, California
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Thomakos P, Mitrakou A, Kepaptsoglou O, Taraoune I, Barreto C, Zoupas CS. The Predictive Low Glucose Management System in Prevention of Clinically Significant Hypoglycemia in Type 1 Diabetes. A Preliminary Study Identifying the Most Common Events Leading Up to Hypoglycemia During Insulin Pump Therapy. Exp Clin Endocrinol Diabetes 2019; 129:385-389. [PMID: 30986882 DOI: 10.1055/a-0889-7598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND/AIM Prevention of hypoglycemia remains a major challenge in diabetic management, despite the introduction of modern insulin pumps in daily clinical practice. The Low Glucose Suspend (LGS) and the newer Predictive Low Glucose Management (PLGM) systems incorporated in the Medtronic insulin pumps have shown promising results in prevention of hypoglycemia. Our aim was to evaluate the effect of the 2 systems relative to the frequency of clinically significant hypoglycemia in Type 1 diabetes (T1DM). In addition, we investigated the events preceding clinically significant hypoglycemia episodes. METHODS A cross-sectional study was conducted in 30 T1DM patients using the MiniMed 640G vs. 30 using the MiniMed Veo sensor-augmented insulin pump. All data was recorded during patients' normal daily activity and living conditions. The patients were matched for age and duration of diabetes. RESULTS PLGM use was associated with lower incidence of clinically significant hypoglycemia (1.9±1.4 vs. 3.6±1.9 episodes per week), along with reduced exposure to hypoglycemia. The data indicated that both pump systems are effective in preventing severe hypoglycemic episodes. In both groups the most common events preceding hypoglycemic episodes included adjustment of hyperglycemia, basal rate increase and miscalculation of carbohydrates. CONCLUSIONS The results indicated that the use of the Minimed 640G pump system can help reduce the frequency of clinically significant hypoglycemia. Management of hyperglycemia must be addressed in diabetes education programs in order to encourage proper adjustment of high blood glucose levels. Future studies would be useful in exploring the details of the events preceding hypoglycemia episodes in insulin pump users.
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Affiliation(s)
- Petros Thomakos
- Diabetes Center and Clinic, Hygeia General Hospital, Marousi, Athens, Greece.,Department of Clinical Therapeutics, National and Kapodistrian University of Athens Alexandra Hospital, Athens, Greece
| | - Asimina Mitrakou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens Alexandra Hospital, Athens, Greece
| | - Olga Kepaptsoglou
- Diabetes Center and Clinic, Hygeia General Hospital, Marousi, Athens, Greece
| | - Ibrahim Taraoune
- Diabetes Center and Clinic, Hygeia General Hospital, Marousi, Athens, Greece
| | - Carol Barreto
- Diabetes Center and Clinic, Hygeia General Hospital, Marousi, Athens, Greece
| | - Christos Sp Zoupas
- Diabetes Center and Clinic, Hygeia General Hospital, Marousi, Athens, Greece
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Efectividad del sistema MiniMed 640G con SmartGuard® para la prevención de hipoglucemia en pacientes pediátricos con diabetes mellitus tipo 1. ENDOCRINOL DIAB NUTR 2017; 64:198-203. [DOI: 10.1016/j.endinu.2017.02.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Revised: 02/08/2017] [Accepted: 02/20/2017] [Indexed: 12/20/2022]
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Bode BW, Kaufman FR, Vint N. An Expert Opinion on Advanced Insulin Pump Use in Youth with Type 1 Diabetes. Diabetes Technol Ther 2017; 19:145-154. [PMID: 28135116 DOI: 10.1089/dia.2016.0354] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Among children and adolescents with type 1 diabetes mellitus, the use of insulin pump therapy has increased since its introduction in the early 1980s. Optimal management of type 1 diabetes mellitus depends on sufficient understanding by patients, their families, and healthcare providers on how to use pump technology. The goal for the use of insulin pump therapy should be to advance proficiency over time from the basics taught at the initiation of pump therapy to utilizing advanced settings to obtain optimal glycemic control. However, this goal is often not met, and appropriate understanding of the full features of pump technology can be lacking. The objective of this review is to provide an expert perspective on the advanced features and use of insulin pump therapy, including practical guidelines for the successful use of insulin pump technology, and other considerations specific to patients and healthcare providers.
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Affiliation(s)
- Bruce W Bode
- 1 Atlanta Diabetes Associates , Atlanta, Georgia
| | - Francine R Kaufman
- 2 The Center for Endocrinology, Diabetes and Metabolism, Children's Hospital Los Angeles , Los Angeles, California
- 3 Medtronic , Northridge, California
| | - Nan Vint
- 4 Lilly USA, LLC, Lilly Corporate Center , US Medical Affairs, Indianapolis, Indiana
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Continuous Glucose Monitoring Sensors: Past, Present and Future Algorithmic Challenges. SENSORS 2016; 16:s16122093. [PMID: 27941663 PMCID: PMC5191073 DOI: 10.3390/s16122093] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 11/17/2016] [Accepted: 12/07/2016] [Indexed: 11/18/2022]
Abstract
Continuous glucose monitoring (CGM) sensors are portable devices that allow measuring and visualizing the glucose concentration in real time almost continuously for several days and are provided with hypo/hyperglycemic alerts and glucose trend information. CGM sensors have revolutionized Type 1 diabetes (T1D) management, improving glucose control when used adjunctively to self-monitoring blood glucose systems. Furthermore, CGM devices have stimulated the development of applications that were impossible to create without a continuous-time glucose signal, e.g., real-time predictive alerts of hypo/hyperglycemic episodes based on the prediction of future glucose concentration, automatic basal insulin attenuation methods for hypoglycemia prevention, and the artificial pancreas. However, CGM sensors’ lack of accuracy and reliability limited their usability in the clinical practice, calling upon the academic community for the development of suitable signal processing methods to improve CGM performance. The aim of this paper is to review the past and present algorithmic challenges of CGM sensors, to show how they have been tackled by our research group, and to identify the possible future ones.
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Barnard K, James J, Kerr D, Adolfsson P, Runion A, Serbedzija G. Impact of Chronic Sleep Disturbance for People Living With T1 Diabetes. J Diabetes Sci Technol 2016; 10:762-7. [PMID: 26630914 PMCID: PMC5038531 DOI: 10.1177/1932296815619181] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
AIM The aim was to explore personal experiences and to determine the impact of impaired sleep on well-being and diabetes-related activities/decision making among a cohort of people living with T1D. METHOD Adults with T1D over the age of 18 and parents/carers of children with T1D were invited to complete an online questionnaire about their quality and quantity of sleep. Questions included impact of sleep on diabetes-related decision making, effective calculation of bolus doses, important aspects of psychosocial functioning, and frequency of waking. Diasend download data were used to objectively determine frequency of nocturnal blood glucose testing in children. RESULTS A total of 258 parent/carer participants (n = 221 female, 85.6%) and 192 adults with T1D (n = 145, 75.5% female, age range 19 to 89 years) took part. In all, 239 parents/carers and 160 adults believed waking in the night has an impact on their usual daily functioning. Of these, 236 parents/carers and 151 (64%) adults reported the impact as negative. Chronic sleep interruption was associated with detrimental impact on mood, work, family relationships, ability to exercise regularly, ability to eat healthily, and happiness. CONCLUSION Chronic sleep interruption is highly prevalent in adults with T1D and parents/carers of children with T1D with negative effects on daily functioning and well-being. Appropriate interventions are required to alleviate this burden of T1D, address modifiable risk factors for nocturnal hypoglycemia, and reduce the (perceived) need for nocturnal waking.
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Affiliation(s)
- Katharine Barnard
- Faculty of Health & Social Science, Bournemouth University, Bournemouth, UK
| | - Janet James
- Faculty of Health & Social Science, Bournemouth University, Bournemouth, UK
| | - David Kerr
- William Sansum Diabetes Center, Santa Barbara, CA, USA
| | - Peter Adolfsson
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Hospital of Halland, Kungsbacka, Sweden
| | - Asher Runion
- Unitio Inc and T1 Diabetes Exchange, Boston, MA, USA
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Polsky S, Giordano D, Voelmle MK, Garcetti R, Garg SK. Using technology to advance type 1 diabetes care among women during the reproductive years and in pregnancy. Postgrad Med 2016; 128:418-26. [PMID: 26924774 DOI: 10.1080/00325481.2016.1159910] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The prevalence of diabetes is increasing globally. Technology to improve care among individuals with diabetes is constantly being developed. Women living with Type 1 Diabetes Mellitus (T1DM) have unique challenges affecting their glucose control relating to menstrual cycles, pregnancy, and menopause. The purpose of this review is to examine the literature related to the use of technology to help women with T1DM manage their diabetes during the reproductive years, pregnancy, and beyond. Continuous subcutaneous insulin infusion (CSII) therapy can provider equivalent or better glucose control when compared with multiple daily injections (MDI), with less hypoglycemia, diabetic ketoacidosis, and weight gain. The CSII therapy has features that could help improve glucose control over the menstrual cycle, menopause, and pregnancy, although the most studied of these stages is pregnancy. Continuous glucose monitoring (CGM) can be combined with any insulin delivery system (MDI or CSII) to provide data on glucose values every few minutes and show glucose trends over time. CGM introduction can highlight glucose variability for women with T1DM, may be beneficial during pregnancy, and can reduce hypoglycemia. Sensor-augmented pump therapy and hybrid artificial pancreas (closed-loop) systems are promising tools that improve outcomes among individuals with diabetes. The use of modern technology to improve glucose and metabolic control among menopausal women with diabetes has not been well studied. Internet and phone-based technologies are emerging as important tools that may help with diabetes self-care for women living with diabetes.
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Affiliation(s)
- Sarit Polsky
- a Barbara Davis Center for Diabetes , Aurora , CO , USA
| | | | | | | | - Satish K Garg
- a Barbara Davis Center for Diabetes , Aurora , CO , USA
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Affiliation(s)
- Anne Phillips
- Senior Lecturer in Diabetes Care, University of York, England
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