State of Type 1 Diabetes Management and Outcomes from the T1D Exchange in 2016-2018

Exploring the intersection of income and race in an age diverse sample of people with Type 1 diabetes

Prior literature suggests that the social gradient in health is racialised such that Black individuals receive fewer health benefits from socioeconomic status than White individuals, yet scarce research studies examine whether this relationship persists in the context of Type 1 diabetes (T1D). Further, most research studies on racial health disparities in T1D outcomes focus on health during early life. We used data from the 2017-2018 wave of the T1D Exchange Registry (N = 11,963) and examined the relationship between household income, race and HbA1c in an age diverse sample of people with T1D. Results revealed that the inverse association between income and HbA1c is stronger for Black T1Ds compared to White T1Ds. Despite this, Black T1Ds with an income of $100,000 or more had higher HbA1c values compared to White individuals with an income of less than $25,000. Further, Black adolescents with T1D had particularly high HbA1c values. There is an urgent need for more research on the interpersonal and structural barriers associated with suboptimal glycaemic control among Black individuals.

Simplified integration of optimal self-management behaviors is associated with improved HbA1c in patients with type 1 diabetes

PURPOSE

Living with type 1 diabetes requires burdensome and complex daily diabetes self-management behaviors. This study aimed to determine the association between integrated behavior performance and HbA1c, while identifying the behavior with the most significant impact on HbA1c.

METHODS

A simple and feasible questionnaire was used to collect diabetes self-management behavior in patients with type 1 diabetes (n = 904). We assessed six dimensions of behavior performance: continuous glucose monitor (CGM) usage, frequent glucose testing, insulin pump usage, carbohydrate counting application, adjustment of insulin doses, and usage of apps for diabetes management. We evaluated the association between these behaviors and HbA1c.

RESULTS

In total, 21.3% of patients performed none of the allotted behavior, while 28.5% of patients had a total behavior score of 3 or more. 63.6% of patients with a behavior score ≥ 3 achieved HbA1c goal, contrasting with only 30.4% of patients with a behavior score of 0-1. There was a mean 0.54% ± 0.05% decrease in HbA1c for each 1-unit increase in total behavior score after adjustment for age, family education and diabetes duration. Each behavior was independently correlated with a lower HbA1c level, with CGM having the most significant effect on HbA1c levels.

CONCLUSIONS

Six optimal self-management behaviors, especially CGM usage, were associated with improved glycemic control, emphasizing the feasibility of implementing a simplified version of DSMES in the routine clinical care.

REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT03610984.

Changes in Self-Efficacy During COVID-19 Among Adolescents With Type 1 Diabetes Mellitus: A Qualitative Study

INTRODUCTION

The purpose of this longitudinal, qualitative study was to examine the impact of the COVID-19 pandemic on self-efficacy and diabetes management among youth diagnosed with type 1 diabetes mellitus (T1DM).

METHODS

We conducted two semi-structured interviews with adolescents diagnosed with T1DM (n = 18) and their maternal caregivers (n = 20) over 6-9 months, to understand how their confidence in the adolescent's ability to manage their diabetes changed during the pandemic. Interviews were transcribed and coded by four raters, establishing inter-reliability.

RESULTS

Four themes emerged: Preventing Adverse Glycemic Events, Useful Glucose Trend Information, Improved Diabetes Management, and Downsides of Technology. Most adolescents (63%) reported increased confidence in their ability to manage diabetes during the pandemic. Over half of these adolescents were already using an insulin pump, and a substantial number (33%) updated their insulin delivery method. Both adolescents and caregivers cited diabetes devices as a factor in their self-efficacy for diabetes management.

DISCUSSION

Findings illustrate the importance of diabetes management in the daily lives of adolescents diagnosed with T1DM, and the potential benefits of diabetes devices during disruptions to care.

Delivering a Smartphone Serious Game-Based Intervention to Promote Resilience for Adolescents With Type 1 Diabetes: A Feasibility Study

INTRODUCTION

The aim of this study is to test the feasibility of a smartphone serious game-based intervention to promote resilience for adolescents with type 1 diabetes mellitus (T1DM).

METHOD

A two-arm feasibility study was employed. Adolescents with T1DM were recruited. Adolescents in intervention group completed the serious game (named "WeCan") in one month. We evaluated feasibility and acceptability using criteria such as the recruitment response rate, the follow-up response rate, and satisfaction.

RESULTS

Sixty-one adolescents with T1DM were included in this study. The study had a recruitment response rate of 62.89% (61/97) and an intervention completion rate of 64.52% (20/31). Eighty-two percent of the adolescents were satisfied with WeCan, which they perceived to have the advantages of being a lively format, attractive, and privacy, easy to operate, and improved attitude towards diabetes.

CONCLUSIONS

These findings suggest that WeCan demonstrated good feasibility among the target population. However, the efficacy of health-related outcomes needs to be clarified in future studies.

Diabetic Retinopathy in Youths-A Potentially Unappreciated Public Health Catastrophe

This Viewpoint discusses the prevalence of youth-onset diabetes and the associated rates of diabetic retinopathy and addresses the need for surveillance of patients with youth-onset diabetes.

Supporting healthy sleep: a qualitative assessment of adolescents with type 1 diabetes and their parents

OBJECTIVE

Poor sleep health is common in adolescence due to a combination of physiological, psychosocial, and environmental factors. Adolescents with type 1 diabetes (T1D) may be at increased risk for poor sleep health due to physiological and behavioral aspects of diabetes and its management. This article describes a qualitative analysis of interviews with adolescents with T1D and their parents about facilitators and barriers to sleep health and family strategies to balance teens' sleep with competing demands.

METHODS

Separate interviews were conducted with 20 adolescents with T1D and 20 parents. Interviews were recorded and transcribed verbatim and analyzed thematically. Participants were on average 15.8 ± 1.2 years old, 45% female, and 85% non-Hispanic White.

RESULTS

Overnight diabetes management was the most frequently reported barrier to sleep. Families reported different strategies for taking responsibility of overnight diabetes management, which differentially impacted sleep. Families worked to balance diabetes management and sleep with other aspects of adolescent life, including school demands, social activities, and electronics use. Facilitators to healthy sleep identified by families included diabetes assistive technology and maintaining a consistent sleep/wake schedule. Both adolescents and parents voiced beliefs that their diabetes care team is not able to help with sleep health.

CONCLUSIONS

Pediatric psychologists should be aware of the specific sleep barriers experienced by adolescents with T1D and their parents. A focus on overnight diabetes management strategies may facilitate psychologists' support of families in the adolescent's transition to independent diabetes management. Research is needed on the impact of optimizing sleep health in adolescents with T1D.

Updated Psychosocial Surveys With Continuous Glucose Monitoring Items for Youth With Type 1 Diabetes and Their Caregivers

AIM

We added items relevant to continuous glucose monitoring (CGM) to the Diabetes Family Conflict Scale (DFC), Diabetes Family Responsibility Questionnaire (DFR), and Blood Glucose Monitoring Communication Questionnaire (GMC) and evaluated the psychometric properties of the updated surveys.

RESEARCH DESIGN AND METHODS

Youth with type 1 diabetes who recently started CGM and their parents completed the updated surveys and additional psychosocial surveys. Medical data were collected from self-reports and review of the medical record.

RESULTS

Youth (N = 114, 49% adolescent girls) were aged 13.3 ± 2.7 years and had mean glycated hemoglobin (HbA1c) 7.9 ± 0.9%; 87% of them used pump therapy. The updated surveys demonstrated high internal consistency (DFC youth: α = .91, parent: α = .81; DFR youth: α = .88, parent: α = .93; and GMC youth: α = .88, parent: α = .86). Higher youth and parent DFC scores (more diabetes-specific family conflict) and GMC scores (more negative affect related to glucose monitoring) were associated with more youth and parent depressive symptoms (r = 0.28-0.60, P ≤ .003), more diabetes burden (r = 0.31-0.71, P ≤ .0009), more state anxiety (r = 0.24 to r = 0.46, P ≤ .01), and lower youth quality of life (r = -0.29 to -0.50, P ≤ .002). Higher youth and parent DFR scores (more parent involvement in diabetes management) were associated with younger youth age (youth: r = -0.76, P < .0001; parent: r = -0.81, P < .0001) and more frequent blood glucose monitoring (youth: r = 0.27, P = .003; parent: r = 0.35, P = .0002).

CONCLUSIONS

The updated DFC, DFR, and GMC surveys maintain good psychometric properties. The addition of CGM items expands the relevance of these surveys for youth with type 1 diabetes who are using CGM and other diabetes technologies.

Control-IQ Technology Use in Individuals With High Insulin Requirements: Results From the Multicenter Higher-IQ Trial

BACKGROUND

Control-IQ technology version 1.5 allows for a wider range of weight and total daily insulin (TDI) entry, in addition to other changes to enhance performance for users with high basal rates. This study evaluated the safety and performance of the updated Control-IQ system for users with basal rates >3 units/h and high TDI in a multicenter, single arm, prospective study.

METHODS

Adults with type 1 diabetes (T1D) using continuous subcutaneous insulin infusion (CSII) and at least one basal rate over 3 units/h (N = 34, mean age = 39.9 years, 41.2% female, diabetes duration = 21.8 years) used the t:slim X2 insulin pump with Control-IQ technology version 1.5 for 13 weeks. Primary outcome was safety events (severe hypoglycemia and diabetic ketoacidosis (DKA)). Central laboratory hemoglobin A1c (HbA1c) was measured at system initiation and 13 weeks. Participants continued using glucagon-like peptide-1 (GLP-1) receptor agonists, sodium-glucose transport protein 2 (SGLT-2) inhibitors, or other medications for glycemic control and/or weight loss if on a stable dose.

RESULTS

All 34 participants completed the study. Fifteen participants used a basal rate >3 units/h for all 24 hours of the day. Nine participants used >300 units TDI on at least one day during the study. There were no severe hypoglycemia or DKA events. Time in range 70-180 mg/dL was 64.8% over the 13 weeks, with 1.0% time <70 mg/dL. Hemoglobin A1c decreased from 7.69% at baseline to 6.87% at 13 weeks (-0.82%, P < .001).

CONCLUSIONS

Control-IQ technology version 1.5, with wider range of weight and TDI input and enhancements for users with high insulin requirements, was safe in individuals with T1D in this study.

Expanding the horizon of continuous glucose monitoring into the future of pediatric medicine

Glucose monitoring has rapidly evolved with the development of minimally invasive continuous glucose monitoring (CGM) using interstitial fluid. It is recommended as standard of care in the ambulatory setting, nearly replacing capillary glucose testing in those with access to CGM. The newest CGM devices continue to be smaller and more accurate, and integration with automated insulin delivery systems has further revolutionized the management of diabetes, leading to successful improvements in care and quality of life. Many studies confirm accuracy and application of CGM in various adult inpatient settings. Studies in adult patients increased during the COVID 19 Pandemic, but despite reassuring results, inpatient CGM use is not yet approved by the FDA. There is a lack of studies in inpatient pediatric settings, although data from the NICU and PICU have started to emerge. Given the exponential increase in the use of CGM, it is imperative that hospitals develop protocols for CGM use, with a need for ongoing implementation research. In this review we describe how CGM systems work, discuss benefits and barriers, summarize research in inpatient pediatric CGM use, explore gaps in research design along with emerging recommendations for inpatient use, and discuss overall CGM utility beyond outpatient diabetes management. IMPACT: Current CGM systems allow for uninterrupted monitoring of interstitial glucose excursions, and have triggered multiple innovations including automated insulin delivery. CGM technology has become part of standard of care for outpatient diabetes management, endorsed by many international medical societies, now with significant uptake, replacing capillary glucose testing for daily management in patients with access to CGM technology. Although CGM is not approved by the FDA for inpatient hospital use, studies in adult settings support its use in hospitals. More studies are needed for pediatrics. Implementation research is paramount to expand the role of CGM in the inpatient setting and beyond.

Low-carbohydrate diet in children and young people with type 1 diabetes: A randomized controlled trial with cross-over design

AIMS

We investigated whether a short period of tightly controlled low-carbohydrate diet (LCD) leads to higher time in range without increasing the associated risks in children and young people with diabetes (CYPwD).

METHODS

Thirty-five (CYPwD) were recruited into this randomized controlled cross-over study (20 female; 20 CSII; age 14.5 ± 2.9 years; HbA1c 48.9 ± 9.4 mmol/mol). The interventions were five and five weeks of ready-made food box deliveries of isocaloric diets in random order: either LCD (94.5 ± 4.7 g/day) or recommended carbohydrate diet (RCD) (191 ± 19.2 g/day). The outcomes were continuous glucose monitoring parameters, anthropometric, laboratory and quality of life (QoL) data.

RESULTS

Time in range was significantly higher in the LCD than in the RCD period (77.1 % vs. 73.8 %, P=0.008). Times in hyperglycemia and average glycaemia were significantly lower in the LCD. There was no difference between the diets in time in hypoglycemia or glycemic variability. The subjects' body weight and BMI were significantly lower during the LCD. There was no significant difference in the LDL-cholesterol levels. No significant differences were observed in the self-assessed QoL.

CONCLUSIONS

Short-term LCD led to an improvement of glycemic parameters without increasing time in hypoglycemia, disturbing the lipid profile or negatively affecting the quality of life of CYPwD.

A Retrospective Cohort Study of Racial/Ethnic and Socioeconomic Disparities in Initiation and Meaningful Use of Continuous Glucose Monitoring Among Youth With Type 1 Diabetes

BACKGROUND

Continuous glucose monitor (CGM) use improves type 1 diabetes (T1D) outcomes, yet children from diverse backgrounds and on public insurance have worse outcomes and lower CGM utilization. Using novel CGM data acquisition and analysis of two T1D cohorts, we test the hypothesis that T1D youth from different backgrounds experience disparities in meaningful CGM use following both T1D diagnosis and CGM uptake.

METHODS

Cohorts drawn from a pediatric T1D program were followed for one year beginning at diagnosis (n = 815, 2016-2020) or CGM uptake (n = 1392, 2015-2020). Using chart and CGM data, CGM start and meaningful use outcomes between racial/ethnic and insurance groups were compared using median days, one-year proportions, and survival analysis.

RESULTS

Publicly compared with privately insured were slower to start CGM (233, 151 days, P < .01), had fewer use-days in the year following uptake (232, 324, P < .001), and had faster first discontinuation rates (hazard ratio [HR] = 1.61, P < .001). Disparities were more pronounced among Hispanic and black compared with white subjects for CGM start time (312, 289, 149, P = .0013) and discontinuation rates (Hispanic HR = 2.17, P < .001; black HR = 1.45, P = .038), and remained even among privately insured (Hispanic/black HR = 1.44, P = .0286).

CONCLUSIONS

Given the impact of insurance and race/ethnicity on CGM initiation and use, it is imperative that we target interventions to support universal access and sustained CGM use to mitigate the potential impact of provider biases and systemic disadvantage and racism. By enabling more equitable and meaningful T1D technology use, such interventions will begin to alleviate outcome disparities between youth with T1D from different backgrounds.

Macroergonomic components of the patient work system shaping dyadic care management during adolescence: a case study of type 1 diabetes

The role of the social, physical, and organisational environments in shaping how patients and their caregivers perform work remains largely unexplored in human factors/ergonomics literature. This study recruited 19 dyads consisting of a parent and their child with type 1 diabetes to be interviewed individually and analysed using a macroergonomic framework. Our findings aligned with the macroergonomic factors as presented in previous models, while highlighting the need to expand upon certain components to gain a more comprehensive representation of the patient work system as relevant to dyadic management. Examples of design efforts that should follow from these findings include expanding existing data sharing options to include information from the external environment and capitalising on the capabilities of artificial intelligence as a decision support system. Future research should focus on longitudinally assessing patient work systems throughout transition periods in addition to more explicitly exploring the roles of social network members.

Transplantation of chemically induced pluripotent stem-cell-derived islets under abdominal anterior rectus sheath in a type 1 diabetes patient

We report the 1-year results from one patient as the preliminary analysis of a first-in-human phase I clinical trial (ChiCTR2300072200) assessing the feasibility of autologous transplantation of chemically induced pluripotent stem-cell-derived islets (CiPSC islets) beneath the abdominal anterior rectus sheath for type 1 diabetes treatment. The patient achieved sustained insulin independence starting 75 days post-transplantation. The patient's time-in-target glycemic range increased from a baseline value of 43.18% to 96.21% by month 4 post-transplantation, accompanied by a decrease in glycated hemoglobin, an indicator of long-term systemic glucose levels at a non-diabetic level. Thereafter, the patient presented a state of stable glycemic control, with time-in-target glycemic range at >98% and glycated hemoglobin at around 5%. At 1 year, the clinical data met all study endpoints with no indication of transplant-related abnormalities. Promising results from this patient suggest that further clinical studies assessing CiPSC-islet transplantation in type 1 diabetes are warranted.

Effectiveness and Safety of GLP-1 Receptor Agonists in Patients with Type 1 Diabetes

Background: GLP-1 receptor agonists (GLP-1RA) are used in the management of type II diabetes mellitus or obesity, although its role in patients with type I diabetes mellitus (T1DM) has been debated. This study aimed to investigate the efficacy and safety of GLP-1RA in patients with T1DM using real-world data. Methods: This multicenter, retrospective study was conducted at three tertiary medical centers in Riyadh, Saudi Arabia. The study followed up patients (>16 years old) with T1DM treated with insulin followed by GLP-1RA add-on therapy. The efficacy outcomes included changes in HbA1c, body weight, and insulin requirements from baseline to each follow-up visit. The main safety outcomes assessed included hypoglycemic events and gastrointestinal (GI) adverse events. Results: The study included 144 patients with a mean age of 33.0 ± 10.1 years. Semaglutide was the most used GLP-1RA (63.9%) followed by liraglutide (34.0%). From baseline to 3-month follow-up, HbA1c (mean difference (MD) = -0.8%; p = 0.0053), weight (MD = -2.4 kg; p = 0.0253), and daily basal insulin dose (MD = -2.1 units; p = 0.0349) were significantly reduced. Likewise, HbA1c (MD = -0.5%; p = 0.0004), weight (MD = -3.6 kg; p < 0.0001), and daily basal insulin (MD = -2.4 units; p = 0.0282) were significantly reduced at the 4-6-month follow-up. The significant reductions in HbA1c, weight, and daily basal insulin levels were consistent for up to 18-month follow-up. Only one patient had a major hypoglycemic event, whereas 8.3% of the patients had GI adverse events. Conclusions: Overall, significant improvements in glycemic control, weight loss, and insulin requirements were observed with the use of GLP-1RA in patients with T1DM, with a limited number of GI adverse events.

Focused on the Family: Development of a Family-Based Intervention Promoting the Transition to Adult Health Care for Adolescents with Type 1 Diabetes

Background/Objectives: There is minimal evidence for current interventions promoting the transition to adult healthcare for youth with type 1 diabetes (T1D). Few interventions exclusively target modifiable individual and family-based factors that contribute to transition readiness. The purpose of this paper is to describe the development of Behavioral Family Systems Therapy for Diabetes Transition (BFST-DT), a virtual family-based transition readiness intervention for adolescents with T1D. Methods: The development of BFST-DT occurred in three phases. In phase 1, focus groups with adolescents and young adults with T1D, their caregivers, and pediatric and adult diabetes providers were conducted to assess perspectives on common family challenges surrounding diabetes management and the transition to adult healthcare. In phase 2, focus group data were used to create video vignettes to be used as part of the intervention. In phase 3, BFST-DT was created through the adaptation of a previous evidence-based family intervention for families of adolescents with T1D. Results: BFST-DT is a virtual, 6-month family-based intervention involving four multi-family group meetings and six individual family meetings. It targets the modifiable and reciprocal interactions among individual and family transition readiness factors. Conclusions: BFST-DT is the first family-focused intervention promoting transition readiness in adolescents with T1D and is currently being tested. Intervention development benefits from prioritization of engagement with patients, caregivers, and providers, as their perspectives are invaluable for creating interventions that are relevant and acceptable to communities.

Predicting risk for nocturnal hypoglycemia after physical activity in children with type 1 diabetes

Children with type 1 diabetes (T1D) frequently have nocturnal hypoglycemia, daytime physical activity being the most important risk factor. The risk for late post-exercise hypoglycemia depends on various factors and is difficult to anticipate. The availability of continuous glucose monitoring (CGM) enabled the development of various machine learning approaches for nocturnal hypoglycemia prediction for different prediction horizons. Studies focusing on nocturnal hypoglycemia prediction in children are scarce, and none, to the best knowledge of the authors, investigate the effect of previous physical activity. The primary objective of this work was to assess the risk of hypoglycemia throughout the night (prediction horizon 9 h) associated with physical activity in children with T1D using data from a structured setting. Continuous glucose and physiological data from a sports day camp for children with T1D were input for logistic regression, random forest, and deep neural network models. Results were evaluated using the F2 score, adding more weight to misclassifications as false negatives. Data of 13 children (4 female, mean age 11.3 years) were analyzed. Nocturnal hypoglycemia occurred in 18 of a total included 66 nights. Random forest using only glucose data achieved a sensitivity of 71.1% and a specificity of 75.8% for nocturnal hypoglycemia prediction. Predicting the risk of nocturnal hypoglycemia for the upcoming night at bedtime is clinically highly relevant, as it allows appropriate actions to be taken-to lighten the burden for children with T1D and their families.

The effect of social support and parental monitoring on glycaemic control in adolescents with type 1 diabetes mellitus

RATIONALE

Glycaemic control is a crucial aspect of managing type 1 diabetes mellitus (T1DM). Strict glycaemic control has been proven to reduce the long-term complications of the disease.

AIMS

The aim of this study was to investigate the effect of parental involvement in diabetes care and social support on glycaemic control in adolescents with T1DM.

METHODS

In this cross-sectional study, 94 adolescents and their parents admitted to a university hospital between January and July 2023 were included in the study. The Multidimensional Scale of Perceived Social Support (PMDC-R) and Parental Monitoring Scale (MSPSS) in Diabetes Care of Adolescents with T1DM were used as data collection tools.

RESULTS

Females constituted 63.8% of the adolescents who participated in the study and the glycaemic control of females was significantly lower than males (p < 0.05). The mean HbA1c of the adolescents was 8.65 + 1.57. In the study, PMDC-R and MSPSS scores of adolescents with good and poor glycaemic control were compared. The PMDC-R of the good control group were statistically significantly higher than the poor control group (p < 0.05), but there was no significant difference between the MSPSS scores.

CONCLUSION

Parental supervision plays a protective role in adolescents, and glycaemic control is better as parental supervision increases. Paediatric nurses should collaborate with parents in diabetes management. This approach may help adolescents to be more successful in diabetes management.

Bridging the gap: a qualitative process evaluation from the perspectives of healthcare professionals of an audit-and-feedback-based intervention to improve transition to adult care for young people living with type 1 diabetes

BACKGROUND

The transition from pediatric to adult care is a vulnerable time for young people living with type 1 diabetes (T1D). Bridging the Gap (BTG) is an audit-and-feedback (AF) intervention aimed at improving both transitions-in-care processes and diabetes management in the year following transition. As part of BTG, we conducted a qualitative process evaluation to understand: (a) what was implemented and how; and (b) the contextual factors (micro-, meso- and macro-) that affected implementation, outcomes and study processes.

METHODS

Using qualitative descriptive methodology, interviews were conducted with 13 healthcare professionals (HCPs) delivering diabetes care to transitioning youth. Participants were asked about their experiences of BTG study processes and feedback tools, the quality improvement (QI) initiatives implemented at their site, and potential spread and scale. Interviews also explored the impacts of COVID-19 on transition care and study processes and results.

RESULTS

Five key themes were identified. Participants' reflections on the BTG study design indicated they appreciated its flexible, site-specific approach to QI, which they saw as crucial to the success of their initiatives. Engagement with feedback reports and other study resources provided comparative, site-specific data. Participants described the challenges posed by the COVID-19 pandemic and its impacts on patients, care provision and study implementation. Their site-specific QI initiatives resulted in changes to their transition practices. Finally, participants commented on how BTG and its processes fostered a community of practice (CoP) between sites, resulting in new opportunities to collaborate and share experiences.

CONCLUSIONS

BTG resulted in a CoP among practitioners delivering transition care to youth with T1D, which could be scaled up to promote a learning health system in pediatric diabetes care. Qualitative process evaluation is a useful tool for understanding how contextual factors affect the implementation and outcomes of complex QI interventions.

Sex disparities in the prevalence, incidence, and management of diabetes mellitus: an Australian retrospective primary healthcare study involving 668,891 individuals

BACKGROUND

In Australia, diabetes is the fastest growing chronic condition, with prevalence trebling over the past three decades. Despite reported sex differences in diabetes outcomes, disparities in management and health targets remain unclear. This population-based retrospective study used MedicineInsight primary healthcare data to investigate sex differences in diabetes prevalence, incidence, management, and achievement of health targets.

METHODS

Adults (aged ≥ 18 years) attending 39 general practices in Western Australia were included. Diabetes incidence and prevalence were estimated by age category. Health targets assessed included body mass index (BMI), blood pressure, blood lipids, and glycated haemoglobin (HbA1c) levels. Medical management of diabetes-associated conditions was also investigated. Time-to-incident diabetes was modelled using a Weibull regression. A multilevel mixed-effects logistic regression model investigated risk-adjusted sex differences in achieving the HbA1c health target (HbA1c ≤ 7.0% (≤ 53 mmol/mol)).

RESULTS

Records of 668,891 individuals (53.4% women) were analysed. Diabetes prevalence ranged from 1.3% (95% confidence interval (CI) 1.2%-1.3%) in those aged < 50 years to 7.2% (95% CI 7.1%-7.3%) in those aged ≥ 50 years and was overall higher in men. In patients younger than 30 years, incidence was higher in women, with this reversing after the age of 50. Among patients with diabetes, BMI ≥ 35 kg/m2 was more prevalent in women, whereas current and past smoking were more common in men. Women were less likely than men to achieve lipid health targets and less likely to receive prescriptions for lipid, blood pressure, or glucose-lowering agents. Men with incident diabetes were 21% less likely than women to meet the HbA1c target. Similarly, ever recorded retinopathy, nephropathy, neuropathy, hypertension, dyslipidaemia, coronary heart disease, heart failure, peripheral vascular disease and peripheral artery disease were higher in men than women.

CONCLUSIONS

This research underscores variations in diabetes epidemiology and management based on sex. Tailoring diabetes management should consider the patient's sex.

Technology and Continuous Glucose Monitoring Access, Literacy, and Use Among Patients at the Diabetes Center of an Inner-City Safety-Net Hospital: Mixed Methods Study

BACKGROUND

Despite the existence of an increasing array of digital technologies and tools for diabetes management, there are disparities in access to and uptake and use of continuous glucose monitoring (CGM) devices, particularly for those most at risk of poor diabetes outcomes.

OBJECTIVE

This study aims to assess communication technology and CGM access, literacy, and use among patients receiving treatment for diabetes at an inner-city safety-net hospital.

METHODS

A survey on digital technology ownership and use was self-administered by 75 adults with type 1 and type 2 diabetes at the diabetes clinic of Grady Memorial Hospital in Atlanta, Georgia. In-depth interviews were conducted with 16% (12/75) of these patient participants and 6 health care providers (HCPs) to obtain additional insights into the use of communication technology and CGM to support diabetes self-management.

RESULTS

Most participants were African American (66/75, 88%), over half (39/75, 52%) were unemployed or working part time, and 29% (22/75) had no health insurance coverage, while 61% (46/75) had federal coverage. Smartphone ownership and use were near universal; texting and email use were common (63/75, 84% in both cases). Ownership and use of tablets and computers and use and daily use of various forms of media were more prevalent among younger participants and those with type 1 diabetes, who also rated them as easier to use. Technology use specifically for diabetes and health management was low. Participants were supportive of a potential smartphone app for diabetes management, with a high interest in such an app helping them track blood sugar levels and communicate with their care teams. Younger participants showed higher levels of interest, perceived value, and self-efficacy for using an app with these capabilities. History of CGM use was reported by 56% (42/75) of the participants, although half (20/42, 48%) had discontinued use, above all due to the cost of the device and issues with its adhesive. Nonuse was primarily due to not being offered CGM by their HCP. Reasons given for continued use included convenience, improved blood glucose control, and better tracking of blood glucose. The in-depth interviews (n=18) revealed high levels of satisfaction with CGM by users and supported the survey findings regarding reasons for continued use. They also highlighted the value of CGM data to enhance communication between patients and HCPs.

CONCLUSIONS

Smartphone ownership was near universal among patients receiving care at an inner-city hospital. Alongside the need to address barriers to CGM access and continued use, there is an opportunity to leverage increased access to communication technology in combination with CGM to improve diabetes outcomes among underresourced populations.

Expansion of Medicaid Coverage of Continuous Glucose Monitor Reduces Health Disparity in Children and Young Adults With Type 1 Diabetes

BACKGROUND

Continuous glucose monitor (CGM) usage improves glycemia in people with type 1 diabetes (PWD) and is accepted as the standard of care. The CGM utilization is lower in patients with public insurance and minorized ethnicities. In 2022, California Medicaid reduced its barriers to obtaining CGM coverage for PWD. It is unknown whether this policy change is sufficient to increase CGM usage. We hypothesize that the change in Medicaid coverage improved CGM uptake in children and young adults with T1D.

METHODS

Data were extracted from electronic medical record of a large urban children's hospital in 2021 and 2022. The CGM usage was determined based on clinician documentation or the presence of CGM downloads. Kruskal-Wallis tests, Wald tests, and χ2 tests were used to test hypothesis (P < .05). Mixed effects logistical regression analyses were performed.

RESULTS

We included 878 and 892 PWD (age ≤ 21 years) in 2021 and 2022, respectively. In 2022, Medicaid insured 59.3% of patients. Between 2021 and 2022, CGM usage did not change for privately insured patients (84%) but increased from 41% to 58% for patients receiving Medicaid. In our mixed effects logistic regression model, CGM usage was higher in 2022 and in English speakers. Public insurance, black race, and patients' age were negatively associated with CGM usage.

CONCLUSION

Our results suggest that Medicaid expansion of CGM coverage increases its utilization for pediatric PWD but did not eliminate the disparity. Future studies are needed to identify barriers that preclude equity in technology uptake.

Experiences of People With Type 1 Diabetes Using the iLet Bionic Pancreas in Primary Care: A Qualitative Analysis

This qualitative substudy sought to identify and understand the experiences of primary care patients with type 1 diabetes using the iLet Bionic Pancreas (Beta Bionics, Inc.) during the first clinical trial testing the automated insulin delivery (AID) system in the primary care setting. Participants in that clinical trial completed a brief semi-structured interview after the trial's completion, during which they were asked questions related to their perceptions of and experiences with using the iLet AID system. Analysis of 16 interviews revealed five major themes, which highlighted the positive and beneficial impact of the system on psychological and behavioral aspects of diabetes management.

TNF-α inhibitors for type 1 diabetes: exploring the path to a pivotal clinical trial

Type 1 diabetes (T1D) is an autoimmune disease characterized by the destruction of insulin-producing β-cells in the pancreas. This destruction leads to chronic hyperglycemia, necessitating lifelong insulin therapy to manage blood glucose levels. Typically diagnosed in children and young adults, T1D can, however, occur at any age. Ongoing research aims to uncover the precise mechanisms underlying T1D and to develop potential interventions. These include efforts to modulate the immune system, regenerate β-cells, and create advanced insulin delivery systems. Emerging therapies, such as closed-loop insulin pumps, stem cell-derived β-cell replacement and disease-modifying therapies (DMTs), offer hope for improving the quality of life for individuals with T1D and potentially moving towards a cure. Currently, there are no disease-modifying therapies approved for stage 3 T1D. Preserving β-cell function in stage 3 T1D is associated with better clinical outcomes, including lower HbA1c and decreased risk of hypoglycemia, neuropathy, and retinopathy. Tumor Necrosis Factor alpha (TNF-α) inhibitors have demonstrated efficacy at preserving β-cell function by measurement of C-peptide in two clinical trials in people with stage 3 T1D. However, TNF-α inhibitors have yet to be evaluated in a pivotal trial for T1D. To address the promising clinical findings of TNF-α inhibitors in T1D, Breakthrough T1D convened a panel of key opinion leaders (KOLs) in the field. The workshop aimed to outline an optimal clinical path for moving TNF-α inhibitors to a pivotal clinical trial in T1D. Here, we summarize the evidence for the beneficial use of TNF-α inhibitors in T1D and considerations for strategies collectively identified to advance TNF-α inhibitors beyond phase 2 clinical studies for stage 3 T1D.

Persistent disparities in insulin pump uptake despite a universal pump programme for type 1 diabetes in Ontario, Canada

AIM

To evaluate associations between social disadvantage and insulin pump use among adults with type 1 diabetes (T1D) in the context of a universal publicly funded insulin pump programme in Ontario, Canada, and to ascertain whether social disparities in insulin pump programme enrolment have decreased over time.

METHODS

Population-based cross-sectional studies were conducted using administrative healthcare data in Ontario, Canada. First, among adults aged older than 18 years diagnosed with T1D before 31 March 2021, logistic regression was used to assess the association between neighbourhood social disadvantage (Ontario marginalization index quintiles) and insulin pump use. Second, among all paediatric and adult applicants to the insulin pump programme from 1 September 2006 to 31 March 2022, ordinal logistic regression was used to evaluate associations between year of insulin pump initiation and social disadvantage.

RESULTS

Among 27 453 adults with T1D, 60% used insulin pumps. Greater social disadvantage was associated with lower odds of insulin pump use (adjusted odds ratio [OR] 0.44 [95% confidence interval {CI} 0.39-0.48] for greatest vs. lowest social disadvantage quintile). Among 21 002 paediatric and adult applicants to the insulin pump programme, social disparities in pump use decreased in the first 3 years of the programme, plateaued until 2020, then increased from 2020 to 2022, with no change in the odds of being in a higher social deprivation quintile for 2022 relative to 2007 (OR 1.09 [95% CI 0.83-1.44]).

CONCLUSIONS

Despite a universal pump programme for individuals with T1D, disparities by social disadvantage persist. Residual financial and non-financial barriers must be addressed to promote equitable insulin pump uptake.

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

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

ADO09, a co-formulation of pramlintide and insulin A21G, lowers body weight versus insulin lispro in type 1 diabetes

AIM

To study safety, efficacy and weight loss with ADO09, a co-formulation of insulin A21G and pramlintide, in type 1 diabetes.

MATERIALS AND METHODS

A randomized, two-arm ambulatory 16-week study compared ADO09 with insulin lispro in 80 participants with type 1 diabetes. We compared changes of weight, glycated haemoglobin, glycaemic patterns during continuous glucose monitoring, and insulin doses at baseline and at the end of treatment.

RESULTS

A significant and continuing weight loss, the primary endpoint, was observed with ADO09 compared with lispro as prandial insulin. In the whole group, the weight loss with ADO09 relative to lispro was 2.1 kg. Glycaemic control was relatively good (7.7% mean glycated haemoglobin) in both groups and did not change during treatment. Prandial insulin doses were reduced by 21% in the ADO09 group, whereas basal insulin dosage was not modified. Gastrointestinal symptoms were more frequent with ADO09, but no clear difference in hypoglycaemia was observed.

CONCLUSIONS

These results extend previous observations on the efficacy and safety of this insulin/pramlintide co-formulation. They show a beneficial effect on weight, using less mealtime insulin and without increased hypoglycaemia.

Use of diabetes technology in children

Children with type 1 diabetes and their caregivers face numerous challenges navigating the unpredictability of this complex disease. Although the burden of managing diabetes remains significant, new technology has eased some of the load and allowed children with type 1 diabetes to achieve tighter glycaemic management without fear of excess hypoglycaemia. Continuous glucose monitor use alone improves outcomes and is considered standard of care for paediatric type 1 diabetes management. Similarly, automated insulin delivery (AID) systems have proven to be safe and effective for children as young as 2 years of age. AID use improves not only blood glucose levels but also quality of life for children with type 1 diabetes and their caregivers and should be strongly considered for all youth with type 1 diabetes if available and affordable. Here, we review key data on the use of diabetes technology in the paediatric population and discuss management issues unique to children and adolescents.

Tirzepatide-Induced Rapid Weight Loss-Related Thyrotoxicosis

This Teachable Moment describes a 62-year-old man with thyrotoxicosis due to excess levothyroxine exposure during tirzepatide treatment that induced rapid weight loss.

Automated Insulin Delivery for Young People with Type 1 Diabetes and Elevated A1c

BACKGROUND

Automated insulin delivery is the treatment of choice in adults with type 1 diabetes. Data are needed on the efficacy and safety of automated insulin delivery for children and youth with diabetes and elevated glycated hemoglobin levels.

METHODS

In this multicenter, open-label randomized controlled trial, we assigned patients with type 1 diabetes in a 1:1 ratio either to use an automated insulin delivery system (MiniMed 780G) or to receive usual diabetes care of multiple daily injections or non--automated pump therapy (control). The patients were children and youth (defined as 7 to 25 years of age) with elevated glycemia (glycated hemoglobin ≥8.5% with no upper limit). The primary outcome was the baseline-adjusted between-group difference in glycated hemoglobin at 13 weeks.

RESULTS

A total of 80 patients underwent randomization (37 to automated insulin delivery and 43 to control) and all patients completed the trial. At 13 weeks, the mean (±SD) glycated hemoglobin decreased from 10.5±1.9% to 8.1±1.8% in the automated insulin delivery group but remained relatively consistent in the control group, changing from 10.4±1.6% to 10.6±1.8% (baseline-adjusted between-group difference, -2.5 percentage points; 95% confidence interval [CI], -3.1 to -1.8; P<0.001). Patients in the automated insulin delivery group spent on average 8.4 hours more in the target glucose range of 70 to 180 mg/dl than those in the control group. One severe hypoglycemia event and two diabetic ketoacidosis events occurred in the control group, with no such events in the automated insulin delivery group.

CONCLUSIONS

In this trial of 80 children and youth with elevated glycated hemoglobin, automated insulin delivery significantly reduced glycated hemoglobin compared with usual diabetes care, without resulting in severe hypoglycemia or diabetic ketoacidosis events. (Funded by Lions Clubs New Zealand District 202F and others; Australian New Zealand Clinical Trials Registry number, ACTRN12622001454763.).

Prognostic Implications of Diabetic Ketoacidosis in Adults on Long-term Mortality and Diabetes-Related Complications

OBJECTIVES

Diabetic ketoacidosis (DKA) occurring after diabetes diagnosis is often associated with risk factors for other diabetes-related complications. In this study, we aimed to determine the prognostic implications of DKA on all-cause mortality and complications in type 1 diabetes (T1D).

METHODS

Previously collected data from the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) study were obtained through the the National Institute of Diabetes and Digestive and Kidney Diseases Central Repository. Using Cox proportional hazards models with time-dependent covariates, we examined age- and sex-adjusted, glycated hemoglobin-adjusted, and fully adjusted associations of DKA with all-cause mortality, cardiovascular disease, microvascular complications, and acute complications over 34 years.

RESULTS

Of the 1,441 study participants, 297 had 488 DKA events. Prior DKA was associated with a higher risk of age- and sex-adjusted all-cause mortality (hazard ratio [HR] 8.28, 95% confidence interval [CI] 3.74 to 18.32, p<0.001), major adverse cardiovascular events (MACEs) (HR 2.05, 95% CI 1.34 to 3.13, p<0.001), and all advanced microvascular and acute complications compared with no prior DKA. Most associations except retinopathy were significant even after adjustment for covariates. In our fully adjusted analysis, prior DKA was associated with a significantly higher risk of subsequent all-cause mortality (HR 9.13, 95% CI 3.87 to 21.50, p<0.001), MACEs (HR 1.66, 95% CI 1.07 to 2.59, p=0.03), advanced kidney disease (HR 2.10, 95% CI 1.00 to 4.22, p=0.049), advanced neuropathy (HR 1.49, 95% CI 1.05 to 2.13, p=0.03), severe hypoglycemia (HR 1.53, 95% CI 1.28 to 1.81, p<0.001), and recurrent DKA (HR 3.24, 95% CI 2.41 to 4.36, p<0.001) compared with person-time without DKA.

CONCLUSIONS

DKA is a prognostic marker for diabetes complications, including excess all-cause mortality. Intensified clinical interventions, such as cardiovascular prevention strategies, may be warranted after diagnosis of DKA.

Evaluation of the transition program at the University Hospital of Reims from 2015 to 2020

The transition of young type 1 diabetic (T1D) patients from pediatric to adult healthcare is a high-risk period of loss to follow-up. Since 2015, we have implemented a transition program, involving both pediatric and adult clinicians. The main objective was to evaluate the number of patients who had succeeded this transition program at 1 year. We found that 86% of patients underwent the complete transition program. However, adverse outcomes occurred in 19.1% of patients at 1 year but decreased to 2.9% after 3 years. In 63% of patients their HbA1c level had deteriorated 1 year after the transition day and this level stabilized at around 8% in the following 2 and 3 years. In patients who had improved HbA1c levels the body mass index was lower (P = 0.03) and they lived alone (P = 0.04). Although our program seemed to allow a better follow-up than previously described, this study highlights the importance of further supporting this transition period.

The Sugar-Coated Truth: The Quality of Diabetes Health Information on TikTok

This study aimed to assess diabetes health information found on TikTok and quantify misinformation on TikTok. The authors assessed 171 videos through two health literacy tools, DISCERN and the Patient Education Materials Assessment Tool for Audiovisual Materials, to rate the understandability and actionability of online medical content. The findings from this study encourage health care professionals to use social media platforms to provide factual information about diabetes and advise online health care consumers to use reputable sources such as trusted diabetes organizations' social media accounts, which tend to validate content with clinicians.

Does insulin pump therapy offer benefits for behaviour, mood, cognition and HbA1c in children and adolescents with type 1 diabetes? A randomised controlled trial with observational follow-up

AIMS

Improved behaviour, mood, cognition and HbA1c have been reported with short-term use of continuous subcutaneous insulin infusion (CSII) in youth with type 1 diabetes (T1D). We sought to re-examine these findings in a randomised controlled trial (RCT), with longitudinal follow-up.

METHODS

RCT of youth aged 7-15 years with T1D, at two tertiary paediatric centres. Participants were randomised to commence CSII or continue multiple daily injections (MDI). Behaviour, mood, cognition and HbA1c were assessed. Primary outcome was difference in parent-reported behaviour (BASC-2) at 4 months. After the 4-month RCT, MDI participants commenced CSII; outcomes were reassessed at +2 years.

RESULTS

Participating youth (n=101) were randomised to CSII (n=56) or MDI (n=45). Significant differences favouring CSII were found at 4 months in parent-reported behaviour problems (Cohen's d 0.41 (95% CI 0.004 to 0.795); p=0.048) and HbA1c (mean (95% CI) difference: 7 (2.3 to 11.7) mmol/mol (0.6% (0.2 to 1.0%); p=0.001)). Improvements from baseline were documented in mood and cognitive outcomes in both study groups over the 4-month RCT; however, no between-group differences were evident at 4 months. Sixteen of 76 (21%) participants completing assessments at +2 years had discontinued CSII. In n=60 still using CSII, measurements of behaviour, mood and HbA1c were comparable to baseline.

CONCLUSIONS

Parent-reported behaviour problems and HbA1c, but not mood or neurocognitive outcomes, were clinically significantly lower with CSII, relative to MDI, after 4 months. Observational follow-up indicated no impact of treatment modality at +2 years, relative to baseline levels. Taken together, these data indicate that use of CSII alone does not comprehensively benefit neuropsychological outcomes in childhood T1D.

Once-weekly insulin efsitora alfa versus once-daily insulin degludec in adults with type 1 diabetes (QWINT-5): a phase 3 randomised non-inferiority trial

BACKGROUND

Insulin efsitora alfa (efsitora) is a once-weekly basal insulin. This phase 3 study aimed to assess the efficacy and safety of efsitora compared with insulin degludec (degludec) in adults with type 1 diabetes.

METHODS

This randomised, 52-week, parallel-design, open-label, treat-to-target non-inferiority study conducted at 82 global health-care centres, randomly assigned (1:1) adults (ie, those aged ≥18 years) with type 1 diabetes glycated haemoglobin A1c (HbA1c) 7·0-10·0% (53·0-85·8 mmol/mol) to efsitora (n=343) or, degludec (n=349), both in combination with insulin lispro. The primary endpoint was the change in HbA1c from baseline to week-26 (non-inferiority margin=0·4%). The trial was registered at ClinicalTrials.gov (NCT05463744) and is completed.

FINDINGS

Between Aug 12, 2022, and May 7, 2024, of 893 participants enrolled, 692 (77%) participants were randomly assigned to once-weekly efsitora or once-daily degludec, and 623 (90%) participants completed the study. Mean HbA1c decreased from 7·88% (62·66 mmol/mol) at baseline to 7·41% (57·5 mmol/mol) at week 26 with efsitora and from 7·94% (63·3 mmol/mol) at baseline to 7·36% (56·9 mmol/mol) at week 26 with degludec. Mean HbA1c change from baseline to week 26 was -0·51% with efsitora and -0·56% with degludec (estimated treatment difference 0·052%, 95% CI -0·077 to 0·181; p=0·43), confirming a non-inferiority margin of 0·4% for efsitora compared with degludec. Rates of combined level 2 (<54 mg/dL [3·0 mmol/L]) or level 3 severe hypoglycaemia were higher with efsitora compared with degludec (14·03 vs 11·59 events per patient year of exposure; estimated rate ratio 1·21, 95% CI 1·04 to 1·41; p=0·016) during weeks 0-52, with the highest rates during weeks 0-12. Severe hypoglycaemia incidence was higher with efsitora (35 [10%] of 343) versus degludec (11 [3%] of 349) during weeks 0-52. Overall incidence of treatment-emergent adverse events was similar across treatment groups. One death not related to the study treatment occurred in the degludec group.

INTERPRETATION

In adults with type 1 diabetes, once-weekly efsitora showed non-inferior HbA1c reduction compared with daily insulin degludec. Higher rates of combined level 2 or level 3 hypoglycaemia and greater incidence of severe hypoglycaemia in participants treated with efsitora compared with participants treated with degludec might suggest the need for additional evaluation of efsitora dose initiation and optimisation in people with type 1 diabetes.

FUNDING

Eli Lilly and Company.

The Interplay between Dietary Habits and Glycemic Control in Type 1 Diabetes: A Comprehensive Prospective FGM Study

Type 1 diabetes has become prevalent among the adult population, who have increasingly gained access to sensing technology. This study delved into the impact of diet, nutritional status, and the use of a continuous glucose monitoring system (CGM) on glycemic regulation among adults diagnosed with T1D. Employing a prospective design, data were gathered from 151 participants aged 18-60 across multiple cycles. Participants utilized the FreeStyle Libre (FSL) Flash Glucose Monitoring (FGM) System and provided dietary details via questionnaires and diaries. The findings unveiled correlations between dietary patterns and glycemic control, with higher protein intake associated with improved glycated hemoglobin A1C values (p = 0.019), yet elevated fat and protein consumption was linked to heightened rates of hyperglycemia. Conversely, no significant relationship was observed between dietary variables and hypoglycemia occurrence. Interestingly, subjects with more readings of glucose levels consumed fewer carbohydrates (p = 0.004) and more proteins (p = 0.000). Furthermore, physical activity and marital status correlated with glycemic stability, while higher education was associated with enhanced glycemic control (p = 0.021). This study confirmed the importance of structured education on glycemic regulation and the importance of dietary patterns in glucose management. Also, the educational role of the FGM system in changing dietary habits was confirmed, which is one of the key factors for improving glycemic regulation in continuous glucose monitoring system users.

Long-Term Glycemic Control Improvement After the Home and Self-Care Program for Patients With Type 1 Diabetes: Real-World-Based Cohort Study

BACKGROUND

The prevalence of type 1 diabetes (T1D) is increasing worldwide, with a much higher proportion of adult patients. However, achieving stable glycemic control is difficult in these patients.

OBJECTIVE

After periodic implementation of structured education for patients with T1D through the Home and Self-Care Program, a pilot home health care project promoted by the Korean government, we evaluated the program's effects on glycemic control.

METHODS

This study was conducted from April 2020 to March 2023. We analyzed 119 participants with T1D aged >15 years. Nursing and nutrition education were provided separately up to 4 times per year, with physician consultation up to 6 times per year. A distinguishing feature of this study compared with previous ones was the provision of remote support using a general-purpose smartphone communication app offered up to 12 times annually on an as-needed basis to enhance the continuity of in-person education effects. Patients were followed up on at average intervals of 3 months for up to 24 months. The primary end point was the mean difference in glycated hemoglobin (HbA1c) at each follow-up visit from baseline. For continuous glucose monitoring (CGM) users, CGM metrics were also evaluated.

RESULTS

The mean HbA1c level of study participants was 8.6% at baseline (mean duration of T1D 10.02, SD 16.10 y). The HbA1c level reduction in participants who received at least 1 structured educational session went from 1.63% (SD 2.03%; P<.001; adjustment model=1.69%, 95% CI 1.24%-2.13% at the first follow-up visit) to 1.23% (SD 1.31%; P=.01; adjustment model=1.28%, 95% CI 0.78%-1.79% at the eighth follow-up visit). In the adjustment model, the actual mean HbA1c values were maintained between a minimum of 7.33% (95% CI 7.20%-7.46% at the first follow-up visit) and a maximum of 7.62% (95% CI 7.41%-7.82% at the sixth follow-up visit). Among CGM users, after at least 1 session, the mean time in the target range was maintained between 61.59% (adjusted model, 95% CI 58.14%-65.03% at the second follow-up visit) and 54.7% (95% CI 50.92%-58.48% at the eighth follow-up visit), consistently staying above 54.7% (corresponding to an HbA1c level of <7.6%). The mean time below the target range (TBR) also gradually improved to the recommended range (≤4% for TBR of <70 mg/dL and ≤1% for TBR of <54 mg/dL).

CONCLUSIONS

The Home and Self-Care Program protocol for glycemic control in patients with T1D is effective, producing significant improvement immediately and long-term maintenance effects, including on CGM indexes.

Mealtime prediction using wearable insulin pump data to support diabetes management

Many patients with diabetes struggle with post-meal high blood glucose due to missed or untimely meal-related insulin doses. To address this challenge, our research aims to: (1) study mealtime patterns in patients with type 1 diabetes using wearable insulin pump data, and (2) develop personalized models for predicting future mealtimes to support timely insulin dose administration. Using two independent datasets with over 45,000 meal logs from 82 patients with diabetes, we find that the majority of people ( ∼ 60%) have irregular and inconsistent mealtime patterns that change notably through the course of each day and across months in their own historical data. We also show the feasibility of predicting future mealtimes with personalized LSTM-based models that achieve an average F1 score of > 95% with less than 0.25 false positives per day. Our research lays the groundwork for developing a meal prediction system that can nudge patients with diabetes to administer bolus insulin doses before meal consumption to reduce the occurrence of post-meal high blood glucose.

Effect of Body Weight on Glycaemic Indices in People with Type 1 Diabetes Using Continuous Glucose Monitoring

Background/Objectives: Obesity and overweight have become increasingly prevalent in different populations of people with type 1 diabetes (PwT1D). This study aimed to assess the effect of body weight on glycaemic indices in PwT1D. Methods: Adult PwT1D using continuous glucose monitoring (CGM) and followed up at a regional academic diabetes centre were included. Body weight, body mass index (BMI), waist circumference, glycated haemoglobin (HbA1c), and standard CGM glycaemic indices were recorded. Glycaemic indices were compared according to BMI, and correlation and linear regression analysis were performed to estimate the association between measures of adiposity and glycaemic indices. Results: A total of 73 PwT1D were included (48% normal weight, 33% overweight, and 19% obese). HbA1c was 7.2% (5.6-10), glucose management indicator (GMI) 6.9% (5.7-8.9), coefficient of variation (CV) for glucose 39.5% ± 6.4, mean glucose 148 (101-235) mg/dL, TIR (time in range, glucose 70-180 mg/dL) 66% (25-94), TBR70 (time below range, 54-69 mg/dL) 4% (0-16), TBR54 (<54 mg/dL) 1% (0-11), TAR180 (time above range, 181-250 mg/dL) 20% ± 7, and TAR250 (>250 mg/dL) 6% (0-40). Glycaemic indices and achievement (%) of optimal glycaemic targets were similar between normal weight, overweight, and obese patients. BMI was associated negatively with GMI, mean glucose, TAR180, and TAR250 and positively with TIR; waist circumference was negatively associated with TAR250. Conclusions: CGM-derived glycaemic indices were similar in overweight/obese and normal weight PwT1D. Body weight and BMI were positively associated with better glycaemic control. PwT1D should receive appropriate ongoing support to achieve optimal glycaemic targets whilst maintaining a healthy body weight.

Not all healthcare inequities in diabetes are equal: a comparison of two medically underserved cohorts

INTRODUCTION

Diabetes disparities exist based on socioeconomic status, race, and ethnicity. The aim of this study is to compare two cohorts with diabetes from California and Florida to better elucidate how health outcomes are stratified within underserved communities according to state location, race, and ethnicity.

RESEARCH DESIGN AND METHODS

Two cohorts were recruited for comparison from 20 Federally Qualified Health Centers as part of a larger ECHO Diabetes program. Participant-level data included surveys and HbA1c collection. Center-level data included Healthcare Effectiveness Data and Information Set metrics. Demographic characteristics were summarized overall and stratified by state (frequencies, percentages, means (95% CIs)). Generalized linear mixed models were used to compute and compare model-estimated rates and means.

RESULTS

Participant-level cohort: 582 adults with diabetes were recruited (33.0% type 1 diabetes (T1D), 67.0% type 2 diabetes (T2D)). Mean age was 51.1 years (95% CI 49.5, 52.6); 80.7% publicly insured or uninsured; 43.7% non-Hispanic white (NHW), 31.6% Hispanic, 7.9% non-Hispanic black (NHB) and 16.8% other. Center-level cohort: 32 796 adults with diabetes were represented (3.4% with T1D, 96.6% with T2D; 72.7% publicly insured or uninsured). Florida had higher rates of uninsured (p<0.0001), lower continuous glucose monitor (CGM) use (18.3% Florida; 35.9% California, p<0.0001), and pump use (10.2% Florida; 26.5% California, p<0.0001), and higher proportions of people with T1D/T2D>9% HbA1c (p<0.001). Risk was stratified within states with NHB participants having higher HbA1c (mean 9.5 (95% CI 8.9, 10.0) compared with NHW with a mean of 8.4 (95% CI 7.8, 9.0), p=0.0058), lower pump use (p=0.0426) and CGM use (p=0.0192). People who prefer to speak English were more likely to use a CGM (p=0.0386).

CONCLUSIONS

Characteristics of medically underserved communities with diabetes vary by state and by race and ethnicity. Florida's lack of Medicaid expansion could be a factor in worsened risks for vulnerable communities with diabetes.

Use of GLP-1 Receptor Agonists for the Management of Type 1 Diabetes: A Pediatric Perspective

BACKGROUND

Despite all the technological advances in treatment of patients with type 1 diabetes (T1D), glucose control remains suboptimal in most patients. In addition, a relatively high percentage of patients with T1D, including children, have obesity. Therefore, new interventions are required that focus their effects on weight loss, in order to help with associated insulin resistance and improve glycemic control.

SUMMARY

GLP-1 receptor agonists (GLP-1 RAs) have proven to be effective and safe in adults with T1D, showing improvement in glycemic control, body weight and cardiorenal protection. GLP-1 RAs are also approved for children with obesity (above the age of 12 years) or type 2 diabetes (above the age of 10 years). However, currently these medications are not approved for use in children with T1D. Only a few published studies have evaluated their efficacy and safety for this indication.

KEY MESSAGE

This review presents the rationale and experience of add-on GLP-1 RA therapy to pediatric and adolescent patients with T1D, otherwise treated, from RCTs and real-world data. Results of studies of GLP-1 RA in children with T1D are still pending, while large multicenter randomized controlled trials (RCTs) in this population are lacking.

Beta-Hydroxybutyrate Levels and Risk of Diabetic Ketoacidosis in Adults with Type 1 Diabetes Treated with Sotagliflozin

Introduction: Sodium glucose cotransporter inhibitors may increase beta-hydroxybutyrate (BHB) in insulin-requiring patients. We determined factors associated with BHB changes from baseline (ΔBHB) and diabetic ketoacidosis (DKA) in patients with type 1 diabetes (T1D) receiving sotagliflozin as an insulin adjunct. Research Design and Methods: This post hoc analysis compared ΔBHB levels in adults with T1D receiving sotagliflozin 400 mg or placebo for 6 months. We evaluated clinical and metabolic factors associated with ΔBHB and used logistic regression models to determine predictors associated with BHB values >0.6 and >1.5 mmol/L (inTandem3 population; N = 1402) or with DKA events in a pooled analysis (inTandem1-3; N = 2453). Results: From baseline (median, 0.13 mmol/L), median fasting BHB increased by 0.04 mmol/L (95% confidence interval, 0.03-0.05; P < 0.001) at 24 weeks with sotagliflozin versus placebo; 67% of patients had no or minimal changes in BHB over time. Factors associated with on-treatment BHB >0.6 or >1.5 mmol/L included baseline BHB and sotagliflozin use. Age, insulin pump use, sotagliflozin use, baseline BHB, and ΔBHB were significantly associated with DKA episodes. Independent of treatment, DKA risk increased by 18% with each 0.1-mmol/L increase in baseline BHB and by 8% with each 0.1-mmol/L increase from baseline. Conclusion: Incremental increases in baseline BHB and ΔBHB were associated with a higher DKA risk independent of treatment. Adding sotagliflozin to insulin increased median BHB over 24 weeks in patients with T1D and was associated with increased DKA events. These results highlight the importance of BHB testing and monitoring and individualizing patient education on DKA risk, mitigation, identification, and treatment.

Parent and adolescent perspectives on a novel transdisciplinary model of healthcare delivery for type 1 diabetes

Objective

We aimed to obtain pre-adolescent/adolescent and parent input on a proposed transdisciplinary model for routine type 1 diabetes (T1D) healthcare in which an advanced practice nurse, dietitian, and psychologist with expertise in T1D and extensive cross-discipline training co-deliver care during quarterly T1D care visits using a family-focused approach.

Methods

Participants were 17 parent-youth dyads plus one additional adolescent who responded to open-ended questions about the structure and format of the proposed transdisciplinary care model via an online, private social network. A six-member coding team developed and revised a codebook, coded question responses through iterative cycles of inductive coding, and distilled major recurring themes to obtain perspectives on the transdisciplinary care model and feedback on improving the model.

Results

We identified nine themes regarding reactions to our proposed transdisciplinary care model, which fell into three broad categories: 1) General Perceptions of Transdisciplinary Care (e.g., Transdisciplinary Care may facilitate improved communication and collaboration among providers and result in more holistic care); 2) Perceptions about Transdisciplinary Care Providers (e.g., Perspectives on the inclusion of dietitians and psychologists as members of the transdisciplinary care team were mixed); and 3) Suggestions for Improving the Transdisciplinary Care Model (e.g., Ensure care is patient/family centered and holistic).

Conclusions

The present findings provided important feedback to modify our transdisciplinary care model and on parent and youth preferences for T1D healthcare delivery.

Accuracy of a Real-Time Continuous Glucose Monitor in Pediatric Diabetic Ketoacidosis Admissions

Objective: Continuous glucose monitoring (CGM) devices are integral in the outpatient care of people with type 1 diabetes, although they lack inpatient labeling. Food and Drug Administration began allowing inpatient use during the coronavirus disease 2019 (COVID-19) pandemic, with some accuracy data now available, primarily from adult hospitals. Pediatric inpatient data remain limited, particularly during diabetic ketoacidosis (DKA) admissions and for patients receiving intravenous (IV) insulin. Design and Methods: This retrospective chart review compared point-of-care glucose values to personal Dexcom G6 sensor data during pediatric hospitalizations. Accuracy was assessed using mean absolute relative difference (MARD), Clarke Error Grids, and the percentage of values within 15/20/30% if glucose value >100 mg/dL and 15/20/30 mg/dL if glucose value ≤100 mg/dL. Results: Matched paired glucose values (N = 612) from 36 patients (median age 14 years, 58.3% non-Hispanic White, 47.2% male) and 42 inpatient encounters were included in this subanalysis of DKA admissions. The MARDs for DKA and non-DKA admissions (N = 503) were 11.8% and 11.7%, with 97.6% and 98.6% of pairs falling within A and B zones of the Clarke Error Grid, respectively. Severe DKA admissions (pH <7.15 and/or bicarbonate <5 mmol/L) had a MARD of 8.9% compared to 14.3% for nonsevere DKA admissions. The MARD during administration of IV insulin (N = 266) was 13.4%. Conclusions: CGM accuracy is similar between DKA and non-DKA admissions and is maintained in severe DKA and during IV insulin administration, suggesting potential usability in pediatric hospitalizations. Further study on the feasibility of implementation of CGM in the hospital is needed.

Diabetes and Technology in Romania: A Patient's Perspective

Professional medical care in the case of diabetes is of utmost importance to ensure patient health, compliance, and comfort. In the past decades, the emergence of healthcare medical devices has also brought important advancements in diabetology. However, this also raised new provocations for patients and healthcare professionals as well, regarding the acceptance, use, and contentment of sensors and pumps in the everyday lives of diabetic patients. The present study aimed to bring more evidence into the possibilities and pitfalls of these medical devices by interrogating 185 diabetic patients through online questionnaires from Romania. The results revealed that the medical devices can complement traditional medical care, and pre-, post-prandial, and nighttime glycemia can be more precisely achieved. Patients have also reported that the sensors and pumps can augment their daily decision-making about glycemic control and ease their daily routine. Contrariwise, the use of these medical devices is related to comfortlessness during sleeping and physical activity. Researchers acknowledge that patients' information, education, and diabetes management, through the opinion of the patients, can augment patient-focused decision-making in the daycare of diabetic patients.

Diabetes Technology Meeting 2023

Diabetes Technology Society hosted its annual Diabetes Technology Meeting from November 1 to November 4, 2023. Meeting topics included digital health; metrics of glycemia; the integration of glucose and insulin data into the electronic health record; technologies for insulin pumps, blood glucose monitors, and continuous glucose monitors; diabetes drugs and analytes; skin physiology; regulation of diabetes devices and drugs; and data science, artificial intelligence, and machine learning. A live demonstration of a personalized carbohydrate dispenser for people with diabetes was presented.

Effectiveness of switching from first-generation basal insulin to Glargine 300 U/mL in children and adolescents with type 1 diabetes: results from the ISPED CARD database

AIMS

Glargine 300 U/mL (Gla-300) has been recently approved for use in children and adolescents with type 1 diabetes (T1D). However, real-world effectiveness data are scarce, and aim of this analysis was to assess clinical outcomes in young patients with T1D switching from 1st generation basal insulin (1BI) to Gla-300.

METHODS

ISPED CARD is a retrospective, multicenter study, based on data anonymously extracted from Electronic Medical Records. The study involved a network of 20 pediatric diabetes centers. Data on all patients aged < 18 years with T1D switching from 1BI to Gla-300 were analyzed to assess clinical characteristics at the switch and changes after 6 and 12 months in glycated hemoglobin (HbA1c), fasting blood glucose (FBG), and standardized body mass index (BMI/SDS). Titration of basal and short-acting insulin doses was also evaluated.

RESULTS

Overall, 200 patients were identified. The mean age at the switch to Gla-300 was 13 years, and mean duration of diabetes was 3.9 years. Average HbA1c levels at switch were 8.8%. After 6 months, HbA1c levels decreased by - 0.88% (95% CI - 1.28; - 0.48; p < 0.0001). The benefit was maintained after 12 months from the switch (mean reduction of HbA1c levels - 0.80%, 95% CI - 1.25; - 0.35, p = 0.0006). Trends of reduction in FBG levels were also evidenced both at 6 months and 12 months. No significant changes in short-acting and basal insulin doses were documented.

CONCLUSIONS

The study provides the first real-world evidence of the effectiveness of Gla-300 in children and adolescents with T1D previously treated with 1BI. The benefits in terms of HbA1c levels reduction were substantial, and sustained after 12 months. Additional benefits can be expected by improving the titration of insulin doses.

Do time preferences predict diabetes outcomes? A combined survey and register-based study

Identifying determinants of heterogeneity in health outcomes continues to be a focus in the health economic literature. In this study, we analyze whether time preferences predict health outcomes in individuals with type 1 diabetes (T1D) who use insulin pump therapy to manage their condition. We collect data on time preferences using a hypothetical matching task and estimate aggregate as well as individual-level discounting parameters using the exponential, hyperbolic, and quasi-hyperbolic discounting models. These parameters are then regressed against essential diabetes-related health outcomes obtained from registries and medical records, including glycemic control, kidney function, BMI, and number of hospital contacts. Our analyses indicate that all three discounting models fit the data equally well. Except for hospital contacts, we find robust evidence that impatience, as reflected by higher discounting, predicts worse health outcomes. Additionally, present bias is associated with worse kidney function. Our findings suggest that time preferences can explain some of the heterogeneity in health among individuals with T1D and call for increased attention on the role of time preferences in the design of disease management programs for individuals with chronic conditions.