Persistently high glucose levels in young children with type 1 diabetes

OBJECTIVES

The aim of the study was to characterize glucose levels and variability in young children with type 1 diabetes (T1D).

METHODS

A total of 144 children of 4-10 yr old diagnosed with T1D prior to age 8 were recruited at five DirecNet centers. Participants used a continuous glucose monitor (CGM) every 3 months during an 18-month study. Among the 144 participants, 135 (mean age 7.0 yr, 47% female) had a minimum of 48 h of CGM data at more than five of seven visits and were included in analyses. CGM metrics for different times of day were analyzed.

RESULTS

Mean hemoglobin A1c (HbA1c) at the beginning and end of the study was 7.9% (63 mmol/mol). Fifty percent of participants had glucose levels >180 mg/dL (10.0 mmol/L) for >12 h/d and >250 mg/dL (13.9 mmol/L) for >6 h/d. Median time <70 mg/dL (3.9 mmol/L) was 66 min/d and <60 mg/dL (3.3 mmol/L) was 39 min/d. Mean amplitude of glycemic excursions (MAGE) was lowest overnight (00:00-06:00 hours). The percent of CGM values 71-180 mg/dL (3.9-10.0 mmol/L) and the overall mean glucose correlated with HbA1c at all visits. There were no differences in CGM mean glucose or coefficient of variation between the age groups of 4 and <6, 6 and <8, and 8 and <10.

CONCLUSIONS

Suboptimal glycemic control is common in young children with T1D as reflected by glucose levels in the hyperglycemic range for much of the day. New approaches to reduce postprandial glycemic excursions and increase time in the normal range for glucose in young children with T1D are critically needed. Glycemic targets in this age range should be revisited.

Diabetes autoantibodies do not predict progression to diabetes in adults: the Diabetes Prevention Program

AIMS

To determine if the presence of diabetes autoantibodies predicts the development of diabetes among participants in the Diabetes Prevention Program.

METHODS

A total of 3050 participants were randomized into three treatment groups: intensive lifestyle intervention, metformin and placebo. Glutamic acid decarboxylase (GAD) 65 autoantibodies and insulinoma-associated-2 autoantibodies were measured at baseline and participants were followed for 3.2 years for the development of diabetes.

RESULTS

The overall prevalence of GAD autoantibodies was 4.0%, and it varied across racial/ethnic groups from 2.4% among Asian-Pacific Islanders to 7.0% among non-Hispanic black people. There were no significant differences in BMI or metabolic variables (glucose, insulin, HbA(1c), estimated insulin resistance, corrected insulin response) stratified by baseline GAD antibody status. GAD autoantibody positivity did not predict diabetes overall (adjusted hazard ratio 0.98; 95% CI 0.56-1.73) or in any of the three treatment groups. Insulinoma-associated-2 autoantibodies were positive in only one participant (0.033%).

CONCLUSIONS

These data suggest that 'diabetes autoimmunity', as reflected by GAD antibodies and insulinoma-associated-2 autoantibodies, in middle-aged individuals at risk for diabetes is not a clinically relevant risk factor for progression to diabetes.

Beneficial effects of intensive therapy of diabetes during adolescence: outcomes after the conclusion of the Diabetes Control and Complications Trial (DCCT)

OBJECTIVE

The Diabetes Control and Complications Trial (DCCT) demonstrated that intensive therapy of type 1 diabetes mellitus reduces the risk of development and progression of microvascular complications. The Epidemiology of Diabetes Interventions and Complications (EDIC) study assessed whether these benefits persisted after the end of DCCT. Results for the adolescent DCCT cohort are reported here.

STUDY DESIGN

Of the DCCT adolescent cohort (n = 195), 175 participated in EDIC, 151 had fundus photography, and 156 had albumin excretion rate measured at year 3 or 4. The odds of progression of retinopathy and albuminuria from closeout of the DCCT until EDIC year 4 were assessed.

RESULTS

In contrast to the 7.4 years of the DCCT, during which mean hemoglobin A(1c) levels were significantly lower with intensive therapy than conventional therapy (8.06% vs 9.76%; P <.0001), the subsequent first 4 years of EDIC had mean hemoglobin A(1c) levels that were similar between the former intensive and the former conventional groups (8.38% vs 8.45%). However, the prevalence of worsening of 3 steps or more in retinopathy and of progression to proliferative or severe nonproliferative retinopathy were reduced by 74% (P <.001) and 78% (P <.007), respectively, in the former intensive therapy group compared with the former conventional group.

CONCLUSIONS

These findings provide further support for the DCCT recommendation that most adolescents with type 1 diabetes receive intensive therapy aimed at achieving glycemic control as close to normal as possible to reduce the risk of microvascular complications.

Behavior therapy for families of adolescents with diabetes: maintenance of treatment effects

OBJECTIVE

This study reports 6- and 12-month follow-up for the families of adolescents with diabetes who participated in a trial of Behavioral-Family Systems Therapy (BFST).

RESEARCH DESIGN AND METHODS

A total of 119 families of adolescents with type 1 diabetes were randomized to 3 months of treatment with either BFST, an education and support (ES) group, or current therapy (CT). Family relationships, adjustment to diabetes, treatment adherence, and diabetic control were assessed at baseline, after 3 months of treatment, and 6 and 12 months later. This report focuses on the latter two evaluations.

RESULTS

Compared with CT and ES, BFST yielded lasting improvements in parent-adolescent relationships and diabetes-specific conflict. Delayed effects on treatment adherence emerged at 6- and 12-month follow-ups. There were no immediate or delayed effects on adolescents' adjustment to diabetes or diabetic control.

CONCLUSIONS

BFST yielded lasting improvement in parent-adolescent relationships and delayed improvement in treatment adherence, but it had no effect on adjustment to diabetes or diabetic control. A variety of adaptations to BFST could enhance its impact on diabetes outcomes.

First-phase insulin release during the intravenous glucose tolerance test as a risk factor for type 1 diabetes

OBJECTIVE

To determine the relationship between first-phase (1 minute + 3 minutes) insulin production during the intravenous glucose tolerance test (IV-GTT) and risk factors for developing type 1 diabetes.

STUDY DESIGN

Relatives of persons with type 1 diabetes (n = 59,600) were screened for islet cell antibodies (ICAs). Subjects who had positive screening results underwent IV-GTT (> or =2 times), repeat ICA screening, insulin autoantibody (IAA) screening twice, and an oral glucose tolerance test.

RESULTS

Of the 59,600 subjects in the study, 2199 (3.69%) had positive findings on initial ICA test. IV-GTTs were performed in 1622 subjects, with children <8 years having the lowest first-phase insulin release (FPIR) and subjects 8 to 20 years of age having the highest FPIR. The FPIR was lower for subjects with a confirmed positive ICA test result or a positive IAA test result, subjects with higher titers of ICA or IAA, and subjects who had an abnormal (impaired or diabetic) oral glucose tolerance test result.

CONCLUSION

FPIR in the IV-GTT correlates strongly with risk factors for development of type 1 diabetes.

Comparison of single-mother and two-parent families on metabolic control of children with diabetes

OBJECTIVE

To understand the impact of family structure on the metabolic control of children with diabetes, we posed two research questions: 1) what are the differences in sociodemographic, family, and community factors between single-mother and two-parent families of diabetic children? and 2) to what extent do these psychosocial factors predict metabolic control among diabetic children from single-mother and two-parent families?

RESEARCH DESIGN AND METHODS

This cross-sectional study included 155 diabetic children and their mothers or other female caregivers. The children were recruited if they had been diagnosed with diabetes for at least 1 year, had no other comorbid chronic illnesses, and were younger than 18 years of age. Interviews and self-report questionnaires were used to assess individual, family, and community variables.

RESULTS

The findings indicate that diabetic children from single-mother families have poorer metabolic control than do children from two-parent families. Regression models of children's metabolic control from single-mother families indicate that age and missed clinic appointments predicted HbA1c levels; however, among two-parent families, children's ethnicity and adherence to their medication regimen significantly predicted metabolic control.

CONCLUSIONS

This study suggests that children from single-mother families are at risk of poorer metabolic control and that these families have more challenges to face when raising a child with a chronic illness. Implications point to a need for developing strategies sensitive to the challenges of single mothers.

Influence of family structure on health among youths with diabetes

Type 1 diabetes mellitus is a chronic metabolic disorder and is one of the most common chronic diseases in childhood. The study discussed in this article examined the extent to which family structure is significantly associated with health in youths with Type 1 diabetes. A convenience sample of 155 children with diabetes and their mothers completed face-to-face interviews; multiple regression analyses were conducted. Findings demonstrated that family structure remains a significant predictor of youths' health when statistically controlling for race, child's age, family socioeconomic status, and adherence. Social workers in outpatient medical settings are in a unique position to develop family-oriented strategies targeting this neglected area of primary care.

Diabetic ketoacidosis in children

Diabetic ketoacidosis is a serious condition that warrants immediate and aggressive intervention. Even with appropriate intervention, DKA is associated with significant morbidity and possible mortality in diabetic patients in the pediatric age group. With appreciation of its severity, proper understanding of the pathophysiology, and careful attention to the details of management and close monitoring, most cases will have a satisfactory outcome. Because treatment is costly and because the risk for morbidity remains even under the best of circumstances, prevention of DKA must be a major goal in the treatment of type 1 diabetes mellitus. Involvement and close follow-up by a multidisciplinary team of health care professionals with experience in dealing with diabetes in children and adolescents is the best way to avoid DKA.

Validation of a structured interview for the assessment of diabetes self-management

OBJECTIVE

The authors developed and validated a semi-structured interview; the Diabetes Self-Management Profile (DSMP), to measure self-management of type 1 diabetes. The DSMP includes the following regimen components: exercise, management of hypoglycemia, diet, blood glucose testing, and insulin administration and dose adjustment.

RESEARCH DESIGN AND METHODS

Families of youths with type 1 diabetes (n = 105) who were entering a controlled trial of intensive therapy (IT) versus usual care (UC) were administered the DSMP Analyses assessed the reliability and validity of the DSMP, including its associations with HbA1c and quality of life.

RESULTS

The DSMP total score has adequate internal consistency (Cronbach's alpha 0.76), 3-month test-retest reliability (Pearson correlation, r = 0.67), inter-interviewer agreement (r = 0.94), and parent-adolescent agreement (r = 0.61). DSMP total scores (r = -0.28) and 3 subscales correlated significantly with HbA1c (diet [r = -0.27], blood glucose testing [r = -0.37], and insulin administration and dose adjustment [r = -0.25 ]). Adolescents' reports of self-management did not differ from parental reports. Higher DSMP scores were associated with more favorable quality of life for mothers and youths.

CONCLUSIONS

The DSMP is a convenient measure that yields a reliable and valid assessment of diabetes self-management. Compared with extant similar measures, the DSMP is more strongly correlated with HbA1c.

Defective insulin receptors in Rabson-Mendenhall syndrome cause complete peripheral insulin resistance but minimal hepatic insulin response remains

In Rabson-Mendenhall syndrome, severe insulin resistance is caused by defective insulin receptors. The patient studied lacks insulin receptor binding due to a truncation mutation of one allele and a point mutation of the other allele of the insulin receptor alpha-subunit. He developed pulmonary hypertension and cor pulmonale, and was considered for organ transplantation. A trial of prednisone 1.2 mg/kg/d was initiated to determine if he could tolerate immunosuppressive therapy without deterioration of his pre-existing, difficult to control diabetes mellitus. Insulin responsiveness was measured prior to and after 4 d of glucocorticoid administration ('Before GC' and 'After GC') using the hyperinsulinemic glucose clamp and stable isotope tracer dilution techniques. After a 12-h fast and 24 h of intravenous insulin, a primed continuous infusion of 6,6-(2)H(2)-glucose was administered during a 2-h tracer equilibration period followed by a 2-h insulin-deficient period, and a 2-h hyperinsulinemic glucose clamp period during which insulin was infused at 7 u/kg/h. Blood glucose concentrations during the basal periods, while no insulin was infused, were 245+/-7 and 138+/-8 mg/dL in the studies Before GC and After GC, respectively. During both hyperinsulinemic glucose clamp periods, the blood glucose was 171+/-1 and 167+/-5 mg/dL, respectively. Hepatic glucose production (HGP) was higher during the basal period Before GC than during the same period After GC (7.86+/-0.23 vs. 5.31+/-0.19 mg/kg/min). HGP rate was suppressed by insulin to 1.48+/-0.45 mg/kg/min Before GC, but was not suppressed After GC (4.19+/-0.81 mg/kg/min). The hyperinsulinemic glucose clamp did not increase the glucose utilization rate nor the glucose clearance rate over basal in either Before GC or After GC, indicating complete peripheral insulin resistance. In summary, the liver showed some response to insulin in the absence of insulin receptors but the peripheral tissues had no response to insulin. Glucocorticoids worsened insulin resistance in the liver in this patient.

Randomized, controlled trial of behavior therapy for families of adolescents with insulin-dependent diabetes mellitus

OBJECTIVE

To describe the short-term results of a controlled trial of Behavioral Family Systems Therapy (BFST) for families of adolescents with diabetes.

METHODS

We randomized 119 families of adolescents with diabetes to 3 months' treatment with either BFST, an education and support Group (ES), or current therapy (CT). Family relationships, psychological adjustment to diabetes, treatment adherence and diabetic control were assessed at baseline, after 3 months of treatment (reported here), and 6 and 12 months later.

RESULTS

Compared with CT and ES, BFST yielded more improvement in parent-adolescent relations and reduced diabetes-specific conflict. Effects on psychological adjustment to diabetes and diabetic control were less robust and depended on the adolescent's age and gender. There were no effects on treatment adherence.

CONCLUSIONS

BFST yielded some improvement in parent-adolescent relationships; its effects on diabetes outcomes depended on the adolescent's age and gender. Factors mediating the effectiveness of BFST must be clarified.

Performance evaluation of the MiniMed continuous glucose monitoring system during patient home use

BACKGROUND

The recent availability of a continuous glucose monitor offers the opportunity to match the demands of intensive diabetes management with a period of equally intensive blood glucose monitoring. The present study evaluates the performance of the MiniMed continuous glucose monitoring system (CGMS) in patients with diabetes during home use.

METHODS

Performance data and demographic information were obtained from 135 patients who were (mean +/- SD) 40.5+/-14.5 years old, had an average duration of diabetes of 18.0+/-9.8 years, 50% were female, 90% were Caucasian, and 87% of whom had been diagnosed with type 1 diabetes. Patients were selected by their physician, trained on the use of the CGMS and wore the device at home for 3 days or more. The performance of the CGMS was evaluated against blood glucose measurements obtained using each patient's home blood glucose meter. Evaluation statistics included correlation, linear regression, mean difference and percent absolute difference scores, and Clarke error grid analysis.

RESULTS

The CGMS values were compared to 2477 SMBG tests (r = 0.91, slope = 0.93, intercept = 14.5 mg/dL, mean absolute difference = 18.0%+/-19.8%). Clarke error grid analysis showed 96.2% of the data pairs falling within the clinically acceptable regions (zones A and B).

CONCLUSIONS

These results demonstrate the agreement of the CGMS to blood glucose meter values, under conditions of home use, in patients selected by their physicians as candidates for continuous monitoring. The detailed glucose information provided by the CGMS should make successful management of diabetes more easily achieved.

Conventional versus intensive diabetes therapy in children with type 1 diabetes: effects on memory and motor speed

OBJECTIVE

Severe hypoglycemia may impair medial temporal-mediated cognitive skills, such as the ability to recall past events explicitly (delayed declarative memory). The objective of this study was to determine whether delayed declarative memory deficits are present in a group of diabetic children with an increased risk of severe hypoglycemia.

RESEARCH DESIGN AND METHODS

Nondiabetic children (n = 16) and children with type 1 diabetes who had been randomly assigned to either intensive (IT) (n = 13) or conventional (CT) (n = 12) diabetes therapy at the time of diagnosis participated in the study. All episodes of severe hypoglycemia were prospectively ascertained. All children were tested on memory tasks that have been closely linked to medial temporal functioning and on reaction time measures.

RESULTS

Our results demonstrated that the IT group had a threefold higher rate of severe hypoglycemia, performed less accurately on a spatial declarative memory task, and performed more slowly, but not less accurately, on a pattern recognition task than did the CT group or control subjects. In addition, both groups of type 1 diabetic children were significantly impaired on a motor speed task compared with their nondiabetic peers.

CONCLUSIONS

These results indicate a selective relative memory impairment associated with IT that is consistent with the effects of severe hypoglycemia and medial temporal damage or dysfunction. If larger prospective studies determine that severe hypoglycemia is the mediating factor for this memory impairment, extreme caution in imposing overly strict standards for glucose control in young patients with type 1 diabetes would be indicated because of the increased risk of hypoglycemia associated with IT regimens.

Memory and insulin dependent diabetes mellitus (IDDM): effects of childhood onset and severe hypoglycemia

Previous studies of the neuropsychological consequences of insulin dependent diabetes mellitus (IDDM) have had mixed and often contradictory results, possibly due to the heterogeneity of the samples and neuropsychological measures, and a lack of specific hypotheses. In order to address this problem, we focused on the effect of severe hypoglycemia on memory functioning in a relatively homogeneous sample of childhood-onset IDDM patients. Given the deleterious effects of hypoglycemia on medial temporal lobe structures (e.g., hippocampus) and the relationship between medial temporal damage and declarative memory functioning, we hypothesized that those patients who had experienced severe hypoglycemia would demonstrate impaired declarative memory and spared nondeclarative memory functioning. Results of the study were generally consistent with this hypothesis, although some impact of hypoglycemia was observed on perceptual priming ability.

Social validity of support group and behavior therapy interventions for families of adolescents with insulin-dependent diabetes mellitus

Compared the social validity of behavior therapy vs. support group interventions for reduction of parent-adolescent conflict among families of adolescents with diabetes. Families were randomized to 10 sessions of an Education and Support group (ES) or 10 sessions of Behavioral Family Systems Therapy (BFST). We compared participants' social validity ratings of BFST and ES using the Treatment Evaluation Questionnaire (TEQ). Mean TEQ scores were significantly more positive for BFST than ES and, for 13 of 20 items, BFST was rated significantly more positively by parents and/or adolescents. Adolescents rated ES less positively than did parents. Fathers' responses reflected fewer differences between ES and BFST. Results extend previous research on BFST and confirm its superiority over ES for targeting family conflict.

Disparity in glycemic control and adherence between African-American and Caucasian youths with diabetes. Family and community contexts

OBJECTIVE

To describe sociodemographic, family, and community factors that contribute to the glycemic control of African-American and Caucasian youths with diabetes, we investigated two questions: 1) Is there a disparity in glycemic control between African-American and Caucasian youths with diabetes, and if so, what sociodemographic, family, and community factors explain the disparity? and 2) Is there a difference in the adherence to treatment between African-American and Caucasian youths with diabetes, and if so, what sociodemographic, family, and community factors explain the difference?

RESEARCH DESIGN AND METHODS

This cross-sectional study included 146 youths with diabetes (95 Caucasians and 51 African-Americans) and their mothers. The youths were invited to participate if they had been diagnosed with diabetes at least 1 year before the study, did not have another chronic illness, and were < 18 years of age.

RESULTS

The findings indicate that African-American youths with diabetes are in significantly poorer metabolic control than their Caucasian counterparts (1.5% difference in HbA1c levels). Single-parent household status and lower levels of adherence partially account for the poorer glycemic control. Examination of the adherence subscales indicates that African-Americans report significantly lower adherence to diet and glucose testing than Caucasian youths.

CONCLUSIONS

This study suggests that African-American youths with diabetes may be at greater risk for poor glycemic control due to the higher prevalence of single parenting and lower levels of adherence found in this population.

Major decrements in glycated hemoglobin levels between 1978 and 1989 in patients with insulin-dependent diabetes mellitus

The Diabetes Control and Complications Trial has shown that intensive treatment can deter the development and progression of diabetic complications. Integral to intensive treatment is improved glycemic control. To describe the trend in glycemic control for subjects with insulin-dependent diabetes mellitus, we examined the medical records of 662 subjects seen between 1978 and 1989 at the Model Demonstration Unit of the Diabetes Research and Training Center (Washington University School of Medicine). Mean value of glycated hemoglobin showed steady decline from a peak of 11.5% in 1979 to 9.0% in 1989. This decline was observed both in subjects evaluated only once (annual rate of decline estimated from linear regression, -0.17 +/1 0.03; p = 0.0001) and in subjects evaluated more than once (annual rate of decline estimated from growth curves, -0.18 +/- 0.06; p = 0.0001). These results suggest that substantial lowering of glycated hemoglobin has occurred during the last decade. This reduction should result in a lowered risk of diabetic complications.

Retinopathy in African Americans and whites with insulin-dependent diabetes mellitus

BACKGROUND

The development and progression of diabetic retinopathy in African Americans with insulin-dependent diabetes mellitus is not known.

METHODS

Two hundred subjects with insulin-dependent diabetes mellitus with duration of diabetes 16 years or less at first visit were studied; 58 were African Americans and 142 were whites. All had gradable stereoscopic color fundus photographs (seven standard fields) from at least two visits (mean time between first and second visit was 4.1 years). Subjects with hemoglobinopathy or proliferative retinopathy or subjects who had evidence of treatment for proliferative retinopathy at first visit were excluded. Masked grading of photographs was conducted using the modified Airlie House classification scheme.

RESULTS

African Americans were older, heavier, had higher systolic blood pressure (all P < .05), and marginally higher hemoglobin A1 (HbA1) values (P = .06) than the whites at first visit. African Americans had a lower rate of two steps or more progression from preexistent retinopathy (19%) than whites (43%). Progression to proliferative retinopathy or treatment was similar by race. Multivariate analysis predicting development oe progression of retinopathy, while controlling for length of follow-up, found higher HbA1 (odds ratio [OR] = 2.15), longer duration of insulin-dependent diabetes mellitus (OR = 1.69), higher serum creatinine concentration (OR = 1.59), and white race (OR = 2.62) to be independent risk factors.

CONCLUSIONS

These data suggest a previously unsuspected reduction in the adjusted risk for development and progression of retinopathy in African Americans. The reason for this apparently reduced risk are not known.

Empowerment: an idea whose time has come in diabetes education

We have learned much in the past 10 years about how to help patients to acquire diabetes-related knowledge and skills and how to use strategies to help patients change behaviors. However, the application of knowledge and techniques should be guided by a relevant, coherent, educational philosophy. Empowerment offers a practical conceptual framework for diabetes patient education. Empowering patients provides them with the knowledge, skills, and responsibility to effect change and has the potential to promote overall health and maximize the use of available resources. It is an idea whose time has come for diabetes education.

Prevalence and consequences of nocturnal hypoglycemia among conventionally treated children with diabetes mellitus

To determine the prevalence and predictors of, and the glucose responses after, nocturnal hypoglycemia, we studied 135 pediatric patients with insulin-dependent diabetes mellitus on 388 nights. The frequencies of blood glucose values less than 60, 50, and 40 mg/dl (3.3, 2.8, and 2.2 mmol/L) at 2 AM were 14.4%, 7.0%, and 2.1%, and at 6 AM were 6.7%, 2.6%, and 0.5%, respectively. Longer duration of diabetes, higher daily insulin doses, and lower glycosylated hemoglobin values were all significant but weak predictors of 2 AM hypoglycemia (glucose less than or equal to 60 mg/dl (less than or equal to 3.3 mmol/L). A 10 PM glucose concentration less than or equal to 100 mg/dl (less than or equal to 5.6 mmol/L) was present on 48% of nights with 2 AM glucose values less than or equal to 60 mg/dl (less than or equal to 3.3 mmol/L), but only 24% of nights with 10 PM blood glucose values less than or equal to 100 mg/dl (less than or equal to 5.6 mmol/L) were followed by 2 AM hypoglycemia. After treatment of 70 episodes of 2 AM glucose concentrations less than or equal to 60 mg/dl (less than or equal to 3.3 mmol/L), mean 6 AM glucose concentration was 95 +/- 6 mg/dl (5.7 +/- 0.3 mmol/L) and less than or equal to 100 mg/dl in 68.6%. In only 4.3% of these cases was the 6 AM glucose concentration greater than 200 mg/dl (greater than 11.1 mmol/L). Among patients who experienced 2 AM hypoglycemia, after-breakfast glucose values were not greater on days with 2 AM hypoglycemia than on days without it. These data indicate that 2 AM hypoglycemia is relatively common in patients with insulin-dependent diabetes mellitus, is frequently preceded by a 10 PM glucose value less than or equal to 5.6 mmol/L, and is less well predicted by other factors. Appropriate treatment of 2 AM hypoglycemia seldom results in either before-breakfast or after-breakfast blood glucose values greater than 200 mg/dl (greater than 11.1 mmol/L). Early-morning hypoglycemia is an uncommon cause of otherwise unexplained, prebreakfast hyperglycemia in children with insulin-dependent diabetes mellitus.

Randomized prospective study of self-management training with newly diagnosed diabetic children

This study was designed to evaluate the effects of a self-management training (SMT) program on metabolic control of children with insulin-dependent diabetes mellitus (IDDM) in the first 2 yr after diagnosis. After standard in-hospital diabetes education, 36 children (mean age 9.3 yr, range 3-16 yr) were randomized to conventional follow-up, conventional and supportive counseling (SC), or conventional and SMT, which emphasized use of data obtained from self-monitoring of blood glucose. SC and SMT interventions consisted of seven outpatient sessions with a medical social worker during the first 4 mo after diagnosis and booster sessions at 6 and 12 mo postdiagnosis. Groups were similar with respect to age, sex, body mass index, socioeconomic status, C-peptide, and severity of illness at diagnosis. Metabolic control, measured quarterly by glycosylated hemoglobin (HbA1), improved substantially in all three treatment groups during the first 6 mo. SMT patients had significantly lower HbA1 levels than conventional patients at 1 yr (P less than 0.01) and 2 yr (P less than 0.05) postdiagnosis. SMT patients also had lower HbA1 levels than SC patients, but this did not reach statistical significance. The lower HbA1 levels of SMT patients were not explained by severity of illness at diagnosis, or insulin dose, body mass index, and C-peptide levels at 2 yr. These results suggest that an SMT program during the first few months after diagnosis helps avoid the deterioration in metabolic control often seen in children with IDDM between 6 and 24 mo after diagnosis.

In-hospital bedside blood glucose monitoring: the importance of a quality control program

This study examined the adequacy of a quality control program to assure accuracy of blood glucose monitoring performed at the bedside by nurses in a general pediatric hospital. A standard quality control program during which all nurses received inservice training and demonstrated proficiency resulted in accuracies (percentage of values within 15% of the laboratory) of only 68.6% and 69.2% over two successive 3-month periods. A standardized refresher course did not improve accuracy. Expansion of the program to include identification and reinstruction of individual nurses who had more than 20% of their blood glucose measurements more than 10% off the laboratory value or any one value more than 40% off the laboratory during the previous quarter resulted in improved accuracies (83%, 78%, and 91%) over three successive 3-month periods. These findings indicate that a systemic quality control program including individual monitoring and remedial retraining is required to improve the long-term accuracy of bedside blood glucose monitoring by nurses in a general pediatric hospital.

Prevalence of cytomegalovirus antibody in subjects between the ages of 6 and 22 years

We determined the prevalence of antibody to cytomegalovirus (CMV) in three groups between 1985 and 1987. Group I consisted of 511 subjects 6-22 y old, group II consisted of 920 subjects 18-21 y old, and group III of 113 subjects 18-22 y old. The overall prevalence of antibody in these three groups was 34%, 24%, and 28%, respectively. Prevalence of antibody in white subjects (24%, 21%, and 24%, respectively) was significantly lower than that in nonwhite subjects. In group I, there was no increase in prevalence with age in white subjects, but the percentage of individuals with antibody increased with age among nonwhite subjects. It is of obvious concern that a large proportion of white women entering childbearing years lack CMV antibody.

The intensive insulin therapy team

The use of a team approach to the management of patients using intensive insulin therapy (IIT) has been supported by policy/position statements of both the American Association of Diabetes Educators and the American Diabetes Association. A course designed and taught by a health care team within the Washington University Diabetes Research and Training Center was offered to 18 multidisciplinary health care teams desiring information about initiating IIT programs. Course outcomes demonstrated positive responses to the team approach to team education but raised questions about the actual composition and functioning of the health care "team." While a well-defined team with IIT knowledge and skills is essential for the development of a comprehensive and safe approach to IIT programs, it is not clear who should be offering these programs.

Self-monitoring of blood glucose by adolescents with diabetes: technical skills and utilization of data

Two studies of adolescent patients were conducted to determine their technical skills and utilization of data obtained by self-monitoring of blood glucose (SMBG). In Study 1, direct observations of 58 adolescents revealed an overall SMBG technical accuracy score of 82%. Most frequent errors were not cleaning fingers (45%), not placing blood on strips correctly (21%), and wiping strip at wrong time (14%). Technical performance was inversely correlated with blood glucose concentration, but was unrelated to other variables. In Study 2, a questionnaire was used to determine SMBG practices among 64 adolescents. Although the majority of patients reported doing daily SMBG, most did not record results in logbooks every time or utilize such data for self-management. No significant relationships were found between SMBG behaviors and other variables. We conclude that periodic evaluation and retraining are required for maintenance of SMBG skills and that methods to enhance utilization of SMBG data be developed for this patient population.

Evaluation of a new system for self blood glucose monitoring

A new combination reflectance meter/visually interpretable system (Glucometer II/Glucostix, Ames Division, Miles Laboratories, Elkhart, IN) has been designed for self blood glucose monitoring. Performance evaluation of this system demonstrates a linear relationship between meter-determined blood glucose values and laboratory-determined whole blood glucose values (y = 0.95x + 2.86, r = 0.97). In addition, 95% of visually interpreted blood glucose values are within one color block of YSI comparative values. Error grid analysis, a new method for determining the clinical accuracy of patient-determined blood glucose results, demonstrated that components of this new system produce clinically accurate blood glucose results.

Dietary skills and adherence in children with type I diabetes mellitus

This study was designed to objectively measure dietary skills of diabetic children and their mothers and to assess dietary adherence in specific situations. Subjects were 34 children with Type I diabetes mellitus and their mothers. Recall of diet prescriptions and performance on skills tests averaged around 50% for both children and mothers. Adherence problems were most frequent during afternoon snack, while at school, with friends, and at restaurants. Significant relationships between glycosylated hemoglobin values and adherence at school and with friends were observed. Older children had more adherence problems with afternoon snack, while alone, and while with parents. Dietary skills were unrelated to adherence. These findings demonstrate that children with diabetes and their mothers have substantial dietary skills deficits and situationally related dietary adherence problems.

Failure of nocturnal hypoglycemia to cause fasting hyperglycemia in patients with insulin-dependent diabetes mellitus

To test the hypothesis that nocturnal hypoglycemia causes fasting hyperglycemia (the Somogyi phenomenon) in patients with insulin-dependent diabetes mellitus, we studied 10 patients, who were on their usual therapeutic regimens, from 10 p.m. through 8 a.m. on three nights. On the first night, only a control procedure was performed (blood sampling only); on the second night, hypoglycemia was prevented (by intravenous glucose infusion, if necessary, to keep plasma glucose levels above 100 mg per deciliter [5.6 mmol per liter]); and on the third night, hypoglycemia was induced (by stepped intravenous insulin infusions between midnight and 4 a.m. to keep plasma glucose levels below 50 mg per deciliter [2.8 mmol per liter]). After nocturnal hypoglycemia was induced (36 +/- 2 mg per deciliter [2.0 +/- 0.1 mmol per liter] [mean +/- SE] from 2 to 4:30 a.m.), 8 a.m. plasma glucose concentrations (113 +/- 18 mg per deciliter [6.3 +/- 1.0 mmol per liter]) were not higher than values obtained after hypoglycemia was prevented (182 +/- 14 mg per deciliter [10.1 +/- 0.8 mmol per liter]) or those obtained after blood sampling only (149 +/- 20 mg per deciliter [8.3 +/- 1.1 mmol per liter]). Indeed, regression analysis of data obtained on the control night indicated that the 8 a.m. plasma glucose concentration was directly related to the nocturnal glucose nadir (r = 0.761, P = 0.011). None of the patients was awakened by hypoglycemia. Scores for symptoms of hypoglycemia, which were determined at 8 a.m., did not differ significantly among the three studies. We conclude that asymptomatic nocturnal hypoglycemia does not appear to cause clinically important fasting hyperglycemia in patients with insulin-dependent diabetes mellitus on their usual therapeutic regimens.

Stress and coping in relation to metabolic control of adolescents with type 1 diabetes

The purpose of this study was to determine whether measures of anxiety, stress, and means of coping with stress differ in diabetic adolescents in good, fair, and poor metabolic control. Trait anxiety, perceived daily stress, and coping responses to a recent stressful event were assessed in 27 adolescents with Type 1 diabetes mellitus. Information also was obtained regarding the type of stressful events that subjects referred to in completing the coping measure, as well as their appraisals of the events. Hemoglobin A1 (HbA1) obtained at the time of the study was used as a measure of antecedent metabolic control. Based upon their HbA1, patients were divided into three metabolic control subgroups: good control (M = 8.4%; n = 8), fair control (M = 10.9%; n = 9), and poor control (M = 13.3%; n = 10). Patients in these subgroups were similar with regard to age, disease duration, and socioeconomic status. Results indicated that the subgroups did not differ on the anxiety and stress measures; however, analyses of the coping data indicated that patients in poor control employed significantly more wishful thinking and avoidance/help-seeking than did patients in good metabolic control. Furthermore, the metabolic control subgroups differed in the type of stressful events reported and their appraisals of the stressful events. These results support the hypothesis that the ways in which individuals with diabetes appraise and cope with stress is related to their metabolic control. The findings are discussed in relation to methodological issues and treatment implications.

The effect of puberty on the development of early diabetic microvascular disease in insulin-dependent diabetes

We studied the prevalence of early diabetic retinopathy and nephropathy in 21 prepubertal and 55 late-pubertal subjects with insulin-dependent diabetes (IDD). All subjects had IDD of 5-7 years duration at the time of evaluation. The prevalence of early diabetic retinopathy was significantly greater in the late-pubertal subjects than prepubertal subjects (33% vs. 9.5%, P = 0.05), despite similar glycosylated hemoglobin values between the two groups (11.7 +/- 2.7% vs. 10.1 +/- 1.6%) at the time of evaluation. Nephropathy was infrequent in late-pubertal subjects (9%), and absent in the prepubertal subjects. We hypothesize that puberty plays an important role in the development of microvascular complications of IDD, and that increases in growth factors, sex hormones and deterioration in glycemic control at the time of puberty may each enhance the development of diabetic microvascular disease.

Acquisition of cytomegalovirus infection from birth to 10 years: a longitudinal serologic study

We performed serial serologic tests for cytomegalovirus (CMV) antibody in 177 children born to low- and middle-income families in Houston from 1975 to 1983. Mean duration of participation in the study was 4.8 years (range 1 to 9.6 years). Most rapid acquisition of antibody occurred during the first and second years of life, 13.6% and 12%, respectively; thereafter, annual acquisition varied from 1.5% to 4.6%, up to 10 years. Overall, 59 (33%) of the group were known to seroconvert by age 10 years. This was a minimal figure because of loss to follow-up. Analysis by the Kaplan-Meier method indicated that the probability of remaining seronegative was 65% at age 6 years, and 58% at age 8 years. Variables positively related to seroconversion by multivariate analysis were order of birth, seroconversion in a family member, and breast-feeding. During the first year of life, acquisition of CMV antibody was related to the seroimmune status of the mother. The variables of socioeconomic status, race, age of the mother, and attendance in a day care center did not appear to be related to seroconversion in these children.

Glycemic control and bone age are independently associated with muscle capillary basement membrane width in diabetic children after puberty

This study was undertaken to examine the possible relationships between muscle capillary basement membrane width (CBMW) and glycemic control, bone age, chronologic age, and duration of diabetes in young patients with insulin-dependent diabetes mellitus (IDDM) during different stages of pubertal development. We studied 49 males and 43 females (age, 7-20 yr) with IDDM for up to 16 yr for whom bone age and glycosylated hemoglobin (HbA1c) data were available at the time of right quadriceps muscle biopsy. Based on pubic hair Tanner stage, subjects were assigned to prepubertal (Tanner I), pubertal (Tanner II and III), and postpubertal (Tanner IV and V) groups. In 30 pubertal and prepubertal subjects, none of the variables studied was significantly correlated with CBMW. This is attributable in part to the small number of subjects in each group. In 62 postpubertal subjects, CBMW was correlated with age (r = .27, P = .03), bone age (r = .43, P = .0005), and postpubertal duration of diabetes (r = .38, P = .003) but not total duration of diabetes. In the postpubertal subjects, CBMW was correlated with HbA1c at the time of biopsy (r = .31, P = .01) but correlated more strongly with the mean of HbA1c values obtained during the 1- and 2-yr periods before biopsy (r = .37, P = .01, and r = .54, P = .03, respectively). An analysis of covariance revealed that the slopes for the regression of loge CBMW on HbA1c differed significantly (P = .02) among the three groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Insulin clearance contributes to the variability of nocturnal insulin requirement in insulin-dependent diabetes mellitus

We have previously described, in insulin-dependent diabetic subjects (IDDM), a small, but significant, increase in the insulin clearance rate (ICR) during 0600-0800 h as compared with 0100-0300 h. To determine whether this increase was also seen at more physiologic levels of insulin replacement, we calculated ICR during euglycemic clamp studies in 13 patients with IDDM with a constant infusion of insulin at 20 mU/min/m2 and during insulin replacement from the Biostator GCIIS without exogenous glucose. During the euglycemic clamp study with constant insulin infusion at 20 mU/min/m2, the ICR was 16% higher at 0600-0800 h than at 0100-0300 h (264 +/- 50 ml/min/m2 versus 228 +/- 51 ml/min/m2; P less than 0.005). During insulin replacement by the Biostator, the mean insulin infusion rate increased by 92 +/- 27% (7.5 +/- 1.1 to 13.5 +/- 1.2 mU/min/m2; P less than 0.001) and ICR increased by 123 +/- 30% (130 +/- 24 to 268 +/- 51 ml/min/m2; P less than 0.01) during the prebreakfast period when compared with 0100-0300 h. There was a highly significant correlation (r = 0.97) between the increment in insulin infusion rate and the increment in ICR. Measurement of insulin concentration in saline solutions, delivered by the Biostator at a same rate and under similar conditions to those in this study, showed that insulin delivery was stable for the 8-h period of this study.(ABSTRACT TRUNCATED AT 250 WORDS)

Failure of ultracentrifugation as a means of separating plasma free insulin from immunoglobulin fraction prior to radioimmunoassay

It has been reported that ultracentrifugation of plasma will allow direct measurement of free insulin in the serum of diabetic subjects with insulin antibodies. To validate this method, we determined recovery of immunoreactive insulin and immunoglobulin G from the plasma of normal individuals after ultracentrifugation. The upper and middle fractions of plasma after ultracentrifugation were evaluated at several combinations of time and temperature (4 degrees C, 25 degrees C, or 37 degrees C for 3, 4 or 5 hours). None of these conditions effectively removed all immunoglobulin G without causing concomitant loss of insulin. We conclude that ultracentrifugation of plasma prior to radioimmunoassay cannot be used to reliably determine free insulin concentration in the plasma from subjects with circulating insulin antibodies.

Plasma pancreatic polypeptide response to insulin-induced hypoglycemia as a marker for defective glucose counterregulation in insulin-dependent diabetes mellitus

Defective glucose counterregulation occurs in some insulin-dependent diabetic subjects (IDDMs) as a result of a combined deficiency of glucagon (IRG) and epinephrine (EPI) secretion in response to insulin-induced hypoglycemia. To determine whether the deficient glucagon response, the deficient epinephrine response, or both are manifestations of autonomic dysfunction, we used the pancreatic polypeptide (PP) secretory response to insulin-induced hypoglycemia as a marker for autonomic neuropathy. Seven nondiabetic controls and 21 IDDMs were given insulin at 40 mU/kg/h after overnight euglycemia. Eight of the IDDMs had defective counterregulation (-CR), and 13 had adequate counterregulation (+CR) by our previously published criteria. Those with -CR had a blunted EPI (delta EPI = 102 +/- 16 pg/ml; mean +/- SEM) and PP (delta PP = 12 +/- 13 pg/ml) response as compared with controls (delta EPI = 310 +/- 49; delta PP = 498 +/- 43) and IDDMs with +CR (delta EPI = 291 +/- 32; delta PP = 521 +/- 86). In controls, IRG rose by 31 +/- 6 pg/ml; in IDDMs, IRG failed to rise significantly above baseline regardless of counterregulatory status. Although the PP and EPI responses correlated well (r = 0.626, P less than 0.001), the IRG response failed to correlate with either the EPI or the PP response. We conclude that the deficient epinephrine, but not glucagon, secretory response to hypoglycemia in diabetic subjects is a result of autonomic neuropathy.(ABSTRACT TRUNCATED AT 250 WORDS)

X-linked glycogen storage disease. A cause of hypotonia, hyperuricemia, and growth retardation

Seven male members of one family had a form of glycogen storage disease that was inherited in an X-linked recessive pattern. The clinical manifestations included hepatomegaly, delay in growth and sexual maturation, muscular weakness in childhood, and gouty arthritis. The cause of the glycogen accumulation did not appear to be a deficiency of glucose 6-phosphatase, debrancher enzyme, phosphorylase, or phosphorylase kinase. Prognosis appeared to be good although there was significant disability during childhood.

Influence of growth hormone on overnight insulin requirements in insulin-dependent diabetes

After a 0100-0300 h nadir, the insulin requirements to maintain blood glucose at 90-110 mg/dl increase substantially in the prebreakfast (0600-0800 h) period in some insulin-dependent diabetic patients (IDDMs). Early insulin-like and delayed insulin-antagonistic effects of physiologic early morning increases in growth hormone (hGH) secretion may account for this variability of overnight insulin requirements. To assess the role of hGH, we studied five IDDMs using a closed-loop insulin infusion device (Biostator, GCIIS). Either saline (C) or somatostatin plus glucagon (SRIF + G) was infused during separate overnight (2400-0800 h) study periods. An infusion of hGH from 2400 to 0130 h was added to SRIF + G infusion during an additional study period (SRIF + G + hGH). In comparison to 0100-0300 h, mean insulin infusion rates required to maintain blood glucose values between 105 and 120 mg/dl during the prebreakfast period increased by 66 +/- 25% during C, and 42 +/- 12% during SRIF + G when serum growth hormone was suppressed to less than or equal to 0.75 ng/ml. During SRIF + G + hGH, the mean prebreakfast insulin infusion rate increased by 42 +/- 11% with a mean peak hGH level of 14.7 +/- 5.4 ng/ml at 0130 h. Mean plasma free insulin levels remained constant during the night despite the significantly higher insulin infusion rates between 0600 and 0800 h. During SRIF + G, insulin requirements remained constant overnight before 0600 h, whereas during both C and SRIF + G + hGH conditions, a nadir was noted between 0100 and 0300 h.(ABSTRACT TRUNCATED AT 250 WORDS)

Defective glucose counterregulation limits intensive therapy of diabetes mellitus

Defective recovery from insulin-induced hypoglycemia, due to combined deficiencies of glucagon and epinephrine secretory responses to plasma glucose decrements, occurs in some patients with insulin-dependent diabetes mellitus (IDDM). Patients with IDDM determined to have inadequate glucose counterregulation during an insulin infusion test (40 mU X kg-1 X h-1) with bedside plasma glucose monitoring and clinical observation have been found to have a 25-fold greater risk of severe hypoglycemia during subsequent intensive therapy than patients with adequate glucose counterregulation. Thus, the efficacy of the glucose counterregulatory systems determines the limits of intensive therapy of IDDM.

The juvenile human endocrine pancreas: normal v idiopathic hyperinsulinemic hypoglycemia

Subtotal pancreatectomy specimens from 11 pediatric patients with idiopathic hyperinsulinemic hypoglycemia (IHH) were studied by conventional light and electron microscopic methods and by morphometric methods applied to sections immunostained specifically for A, B, D, and PP cells. The results were compared with corresponding studies of pancreata obtained at autopsy of 31 infants and children without abnormalities in carbohydrate homeostasis. In the control tissue, the total volume density of islet cells in live born premature infants (n = 12) was about 20%, in live born term newborn infants (0 to 1 months, n = 9) between 17.5% and 20%, in infants (1 to 7 months, n = 5) about 10%, and in children (1.5 to 11 years, n = 5) about 7.5%. Endocrine tissue was as abundant in the body and head as in the tail of the pancreata. The contribution of PP cells to total islet cell mass increased with age, and for the relative contribution of PP cell compared with total pancreatic parenchyma it remained relatively constant, while that of A, B, and D cells decreased with age. A wide spectrum of islet cell aggregates was a normal feature of development in the control tissue, an observation accentuated by specific immunocytochemical staining. Islet cells of all types were present singly and in small clusters in pancreatic ductal structures and intimately related to acini; nesidioblastosis, therefore, is a feature of normal maturation of the pancreas. Seven of the 11 cases of IHH had pancreata that were morphologically and morphometrically normal for age. No anatomic basis for hyperinsulinism in these cases was apparent. Four pancreata from patients with IHH contained discrete foci of proliferation of islet cells of all types but in which B cells greatly predominated. We conclude that nesidioblastosis as a morphologic diagnosis cannot be viewed as the structural basis of endocrine dysfunction since it can be absent in IHH, or many of its features present in control pancreata.

Relative roles of insulin clearance and insulin sensitivity in the prebreakfast increase in insulin requirements in insulin-dependent diabetic patients

During continuous subcutaneous or intravenous insulin infusion therapy, many patients with insulin-dependent diabetes (IDD) require more insulin in the prebreakfast period (0600-0800 h) than earlier in the morning (0100-0300 h). This study was designed to assess whether variations in insulin clearance or insulin sensitivity might contribute to overnight variations in insulin requirements. Euglycemic insulin clamp studies were performed in random sequence from 2400 to 0300 h and from 0500 to 0800 h on successive nights in 10 subjects with IDD. Insulin was infused at a rate of 40 mU/min/m2 and plasma glucose concentration was maintained at 100 mg/dl by a variable rate glucose infusion from a Biostator GCIIS (Miles Laboratories, Elkhart, Indiana). Insulin clearance was (mean +/- SEM) 277 +/- 41 ml/min/m2 between 0700 and 0800 h compared with 256 +/- 41 ml/min/m2 between 0200 and 0300 h (P less than 0.05), while glucose infusion rates were the same [3.86 +/- 0.52 mg/kg/min from 0730 to 0800 h versus 3.99 +/- 0.51 mg/kg/min from 0230 to 0300 h (P = NS)]. All eight patients with a previously documented prebreakfast increase in insulin requirements had higher insulin clearance at this time. These results indicate that differences in insulin clearance between the prebreakfast period and the early morning may account partially for the higher prebreakfast insulin requirements in some subjects with IDD, and the variations in insulin requirements during the night are not due to variations in insulin sensitivity.