Diabetes Study of Children of Diverse Ethnicity and Race: Study design

AIMS

Determining diabetes type in children has become increasingly difficult due to an overlap in typical characteristics between type 1 diabetes (T1D) and type 2 diabetes (T2D). The Diabetes Study in Children of Diverse Ethnicity and Race (DISCOVER) programme is a National Institutes of Health (NIH)-supported multicenter, prospective, observational study that enrols children and adolescents with non-secondary diabetes. The primary aim of the study was to develop improved models to differentiate between T1D and T2D in diverse youth.

MATERIALS AND METHODS

The proposed models will evaluate the utility of three existing T1D genetic risk scores in combination with data on islet autoantibodies and other parameters typically available at the time of diabetes onset. Low non-fasting serum C-peptide (<0.6 nmol/L) between 3 and 10 years after diabetes diagnosis will be considered a biomarker for T1D as it reflects the loss of insulin secretion ability. Participating centres are enrolling youth (<19 years old) either with established diabetes (duration 3-10 years) for a cross-sectional evaluation or with recent onset diabetes (duration 3 weeks-15 months) for the longitudinal observation with annual visits for 3 years. Cross-sectional data will be used to develop models. Longitudinal data will be used to externally validate the best-fitting model.

RESULTS

The results are expected to improve the ability to classify diabetes type in a large and growing subset of children who have an unclear form of diabetes at diagnosis.

CONCLUSIONS

Accurate and timely classification of diabetes type will help establish the correct clinical management early in the course of the disease.

Substantial Intra-Individual Variability in Post-Prandial Time to Peak in Controlled and Free-Living Conditions in Children with Type 1 Diabetes

The optimal time to bolus insulin for meals is challenging for children and adolescents with type 1 diabetes (T1D). Current guidelines to control glucose excursions do not account for individual differences in glycaemic responses to meals. This study aimed to examine the within- and between-person variability in time to peak (TTP) glycaemic responses after consuming meals under controlled and free-living conditions. Participants aged 8–15 years with T1D ≥ 1 year and using a continuous glucose monitor (CGM) were recruited. Participants consumed a standardised breakfast for six controlled days and maintained their usual daily routine for 14 free-living days. CGM traces were collected after eating. Linear mixed models were used to identify within- and between-person variability in the TTP after each of the controlled breakfasts, free-living breakfasts (FLB), and free-living dinners (FLD) conditions. Thirty participants completed the study (16 females; mean age and standard deviation (SD) 10.5 (1.9)). The TTP variability was greater within a person than the variability between people for all three meal types (between-person vs. within-person SD; controlled breakfast 18.5 vs. 38.9 min; FLB 14.1 vs. 49.6 min; FLD 5.7 vs. 64.5 min). For the first time, the study showed that within-person variability in TTP glycaemic responses is even greater than between-person variability.

Effect of Nutritional Habits on the Glycemic Response to Different Carbohydrate Diet in Children with Type 1 Diabetes Mellitus

Unhealthy eating habits are associated with obesity, metabolic syndrome, and increased insulin resistance in young patients with type 1 diabetes mellitus (T1DM), and may impact the possible benefit from dietary interventions on glycaemic control. This study determines how nutritional patterns influence the quality of dietary intervention with a 30% or 50% carbohydrate diet in terms of glycaemic control measured with continuous glucose monitoring (CGM). Eating habits were obtained with a frequency-of-consumption questionnaire (FFQ-6) before the diet assessment. Altogether, we collected CGM and FFQ-6 data from 30 children (16 boys and 14 girls aged 10-17 years) with T1DM subjected to two consecutive 3-day nutritional plans. From these, 23 patients met the CGM data quality criteria for further analysis. Furthermore, high accuracy achieved in training (95.65%) and V-fold cross-validation (81.67%) suggest a significant impact of food habits in response to introduced nutritional changes. Patients who consumed more vegetables or grains (>4 times per day), more wheat products (>once per day), fewer fats (<1.5 times per day), and ranked fruit juice as the most common selection in the drinks category achieved glycaemic control more often after the introduction of a 30% carbohydrate diet, as opposed to those with different dietary patterns, whose glycaemic control was negatively impacted after switching to this diet. Additionally, the 50% carbohydrate diet was safe for all patients in the context of glycaemic control.

Reconsidering a role for attachment in eating disorder management in the context of paediatric diabetes

We suggest a reconsideration of the role of 'attachment orientation' in the context of eating disorders and paediatric diabetes. Attachment orientation is a psychological construct that describes a relatively stable set of expectations and behaviours an individual relies upon in managing relationships. There is considerable evidence of an association between attachment orientation and the development and maintenance of disordered eating in individuals without diabetes, though evidence is more scant in populations with diabetes. We discuss the underpinning theory and critically examine the existing literature for the relationship between attachment orientation and disordered eating in paediatric diabetes. Finally, we draw on adjacent literatures to highlight potential future directions for research should this area be revisited. Overall, we contextualise our discussion in terms of patient-centred, holistic care that addresses the mind and body (i.e., our discussion of attachment orientation assumes a psycho-biological approach).

Using telehealth for rural paediatric diabetics: Does it deliver good care?

AIM

To evaluate rural paediatric diabetic telehealth clinics including whether they meet clinical standards, provide equivalent care to central clinics, families were satisfied and difficulties were encountered.

METHODS

An audit of a telehealth service for children and adolescents with type 1 diabetes mellitus at four rural sites was conducted. The case notes for each patient for 2019 were reviewed to determine if standards of paediatric diabetic care were met. Interviews were conducted at a clinic at each site with the child, parent(s) and staff attending the clinics. A retrospective review of difficulties in service provision was undertaken with staff.

RESULTS

Nineteen children and adolescents were seen in the telehealth clinics over the year. Eighteen (95%) were seen four times with point-of-care measurement of glycosylated haemoglobin (HbA1c) and growth by the consultant paediatrician and diabetic nurse educator. Complication screening was achieved on time for 15 (78%) patients, with the remaining patients having had the tests ordered. Eleven (56%) patients were reviewed by a dietician, six (33%) by social worker and five (27%) by psychologist. All patients and parents reported receiving good support for their diabetes without any preferring to attend the central clinic. There were no significant technical difficulties.

CONCLUSION

Providing paediatric diabetic care through a telehealth service at rural hospitals meets standards of care and was provided without technical difficulties. It is preferred by patients and their parents to attending a central clinic. A model of service is presented that may be replicated elsewhere in Australia.

Insulin/carbohydrates ratio during the first 6-month therapy with insulin degludec in a paediatric population with type 1 diabetes previously treated with insulin glargine. An observational longitudinal study

BACKGROUND

No data exist about the changes induced by the transition from first-generation long-acting insulins to second-generation long-acting analogues in the paediatric population.

OBJECTIVE

To assess changes in insulin/carbohydrate ratio (I:CHO) after the first 6 months of degludec therapy in a paediatric population with type 1 diabetes previously treated with glargine U100.

SUBJECTS

All patients treated with degludec under routine clinical practice conditions were retrospectively analysed.

METHODS

Nonprofit observational retrospective study. Changes during the follow-up in mean CHO/I ratio were assessed using longitudinal linear models for repeated measures. Rate of hypoglycaemia, ketoacidosis and adverse events was evaluated.

RESULTS

Overall, 51 children (mean age 13.8 ± 4.6 years; mean diabetes duration 5.8 ± 3.9 years) started therapy with degludec in the period between April 2017 and April 2018. I:CHO ratio before starting degludec therapy significantly differed among the three meals, being the lowest at breakfast and the highest at dinner. After introducing degludec, I:CHO ratio at lunch (-1.29 95% CI -2.02;-0.57) and at dinner (-3.08 95% CI -4.35;-1.8) significantly decreased, while it slightly increased at breakfast (+1.37 95% CI 0.47;2.28). No episodes of severe hypoglycaemia, ketoacidosis and adverse event were recorded during 6 months.

CONCLUSIONS

Our data show that the use of degludec is associated with a significant change in the I:CHO ratio at the different meals compared to the previous glargine therapy. This could derive from the flat and prolonged pharmacokinetic profile of degludec. This has important clinical implications for daily insulin dose adjustments.

Online survey to assess parents' experience and preferences for follow-up visits for children living with type 1 diabetes in Quebec, Canada: a study protocol

INTRODUCTION

It is accepted that although patients may initiate a visit to a healthcare provider, follow-up visits are often based on recommendations from providers. This suggests that follow-up care, since not initiated by patients, may not reflect patients' perception of a need for care. However, few studies have examined the burden of regular follow-up care and patients' perceived value of such care. For parents of children with type 1 diabetes (T1D), follow-up visits are scheduled regardless of how well controlled the diabetes is. Our study examines how benefits and burden from the parents' perspective could affect their preferences in regard to the frequency of regular follow-up care.

METHODS

We aim to develop an online patient survey to be distributed to parents of children living with T1D in the province of Quebec, Canada. The survey will be available in French and English, and distributed through diabetes clinics, on social media groups and forums for parents of children with T1D. The survey will be developed in collaboration with parents of children with T1D to ensure that it appropriately reflects the services in regular follow-up care and that the language is understandable and clear.

ETHICS AND DISSEMINATION

All participants will be informed of the requirements and objectives of the survey at the beginning of the questionnaire and that the data collected will remain anonymous and confidential. Ethics approval for the study was obtained from the research ethics committee of the CHU de Québec-Université Laval. Results of the study will be shared with relevant stakeholders with the aim of improving practices and better meeting patients' and families' needs.

Microvascular complications among patients with diabetes: An emerging health problem in Saudi Arabia

Diabetes mellitus, besides disrupting the carbohydrate metabolism process, also induces vascular disease and impacts nearly all the types and sizes of blood vessels. In fact, vascular complications cause majority of the morbidity, hospitalizations and mortality of patients with diabetes mellitus. Retinopathy, nephropathy and neuropathy (microvascular complications) impact hundreds of millions of diabetics and normally target those having long-term or uncontrolled forms of the disease; however, these disorders can also exist at the time of diagnosis or in those yet to be diagnosed. The Kingdom of Saudi Arabia is the biggest country in the Middle East that occupies around four-fifths of the Arabian Peninsula supporting a population of more than 33.3 million people. The prevalence of diabetes mellitus is increasing at an alarming rate in Saudi Arabia. Over 25% of the adult population is suffering and that figure is projected to more than double by 2030. In fact, diabetes mellitus has approximately registered a 10-fold upsurge in the past three decades in Saudi Arabia. However, the prevalence and risk factors of microvascular complications in diabetes mellitus patients have not yet been clearly documented in Saudi Arabia. Hence, in this review, we aim to provide an overview of the microvascular complications among patients with diabetes in Saudi Arabia, utilizing data from the currently available published literature. This is an attempt to facilitate the government and healthcare systems aware of the enormous worth of prevention, early detection and appropriate management of such microvascular complications.

Three-year comparison of subcutaneous insulin pump treatment with multi-daily injections on HbA1c, its variability and hospital burden of children with type 1 diabetes

Treatment with continuous subcutaneous insulin infusion (CSII) allows a large degree of treatment individualization and intensification in children with diabetes. The study's aim was to evaluate the impact of treatment with CSII on glycated haemoglobin level (HbA1c) in children with diabetes and investigate whether introduction of CSII is associated with an increased risk of acute complications of diabetes. Patients treated throughout the recruitment period exclusively with multiple daily injections (MDI) were matched for duration of diabetes and HbA1c level at baseline with patients treated exclusively with CSII in a 1:1 group ratio (n = 223 and 231 for MDI and CSII, respectively). The CSII group showed lower HbA1c after the observation period (7.98 ± 1.38 vs. 7.56 ± 0.97; P = 0.002). HbA1c variability measured as standard deviations of average values was also lower in the CSII group (0.73 ± 0.45 vs. 0.84 ± 0.54; P = 0.049). The rate of hospitalization due to acute events was similar in both groups (14.7/100 vs. 14.0/100 person/years in the MDI and CSII group, P = 0.72). Duration of hospital stay per year was on average 1.25 days shorter in the CSII group (P = 0.0004), but the risk of acute complications resulting in hospitalization did not differ between the groups (hazard ratio (HR) 1.16; 95% confidence interval (95% CI) 0.68-1.63). The most significant risk factor for hospitalization due to acute complications was baseline HbA1c concentration (HR 1.25; 95% CI 1.14-1.37). In conclusion, CSII treatment may improve glycemic control and reduce its variability. Change of MDI to CSII does not alter the risk of hospitalization and may reduce the annual duration of hospitalization in children with diabetes.