Frequency of SMBG correlates with HbA1c and acute complications in children and adolescents with type 1 diabetes

7. Diabetes Technology: Standards of Medical Care in Diabetes-2019

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Mealtime insulin bolus adherence and glycemic control in adolescents on insulin pump therapy

Poor self-management contributes to insufficient glycemic control in adolescents with type 1 diabetes (T1DM). We assessed the effects on glycemic control of adherence to self-measurement of blood glucose (SMBG) and insulin boluses in 90 adolescents with T1DM on insulin pump therapy over a 2-month period. We compared the number of insulin boluses and SMBGs around main meals to the "gold standard" of optimal diabetes management (SMBGs and a bolus before each main meal and SMBG before bedtime). The mean (95% CI) HbA1c levels were 2.9(1.7 to 4.0) mmol/mol lower for every additional insulin bolus and 3.1(1.6 to 4.5) mmol/mol lower for every additional SMBG. Patients performing SMBG and bolusing around each main meal had considerably lower HbA1c levels than those unable to do (95% CI for difference 4.3 to 10.4 mmol/mol and 11.5 to 20.1 mmol/mol respectively). For each additional mealtime bolus/day, the odds ratio of achieving target HbA1c levels of <58 mmol/mol was 6.73 (95% CI 2.94-15.38), after adjustment for gender, age, diabetes duration, and affective responses to SMBG in a multiple logistic regression model.Conclusion: Glycemic control in adolescents with T1DM on insulin pump therapy is strongly dependent on adherence to insulin boluses around mealtimes. What is Known: • In mixed groups of children and adolescents, insulin bolus frequency and self-monitoring of blood glucose (SMBG) frequency were determinants of HbA1c levels. • Adherence to insulin boluses and SMBG is particularly challenging in adolescents. What is New: • In adolescents on insulin pump therapy, each additional insulin bolus, particularly around mealtime, was significantly associated with approximately 3 mmol/mol lower HbA1c levels. • This beneficial effect of mealtime bolusing was strongest for the evening meal.

Frequency of Self-Monitoring of Blood Glucose during the School Day Is Associated with the Optimal Glycemic Control among Korean Adolescents with Type 1 Diabetes

BACKGROUND

This study aimed to evaluate the relationship between the frequency of self-monitoring of blood glucose (SMBG) and glycosylated hemoglobin (HbA1c) levels among Korean adolescents with type 1 diabetes mellitus (T1DM). Factors affecting the SMBG frequency were analyzed in order to improve their glycemic control.

METHODS

Sixty-one adolescents aged 13 to 18 years with T1DM were included from one tertiary center. Clinical and biochemical variables were recorded. Factors associated with SMBG frequency were assessed using structured self-reported questionnaires.

RESULTS

Average total daily SMBG frequency was 3.8±2.1 and frequency during the school day was 1.3±1.2. The mean HbA1c level was 8.6%±1.4%. As the daily SMBG frequency increased, HbA1c levels declined (P=0.001). The adjusted odds of achieving the target HbA1c in participants who performed daily SMBG ≥5 significantly increased 9.87 folds (95% confidence interval [CI], 1.58 to 61.70) compared with those performed SMBG four times a day. In the subjects whose SMBG frequency <1/day during the school day, an 80% reduction in the adjusted odds ratio 0.2 (95% CI, 0.05 to 0.86) showed compared to the group with performing two SMBG measurements in the school setting. The number of SMBG testing performed at school was significantly high for individuals assisted by their friends (P=0.031) and for those who did SMBG in the classrooms (P=0.039).

CONCLUSION

Higher SMBG frequency was significantly associated with lower HbA1c in Korean adolescents with T1DM. It would be necessary to establish the school environments that can facilitate adequate glycemic control, including frequent SMBG.

Use of flash glucose-sensing technology (FreeStyle Libre) in youth with type 1 diabetes: AWeSoMe study group real-life observational experience

AIMS

Frequent glucose testing is required for optimal management of type 1 diabetes (T1D). Limited data are available regarding real-world experience of the novel technology for monitoring by continuous interstitial fluid glucose (IFG), using flash glucose-sensing technology (FSL-CGM). We aimed to assess the effect of FSL-CGM in a real-life clinical setting on glycemic control parameters, compliance, and adverse events among pediatric and young adult T1D patients.

METHODS

This observational multi-center study assessed FSL-CGM use (6-12 months) in T1D patients (mean ± SD age 13.4 ± 4.9 years) who purchased the device out-of-pocket. Outcome measures included HbA1c, mean IFG levels, CGM metrics [time in hypoglycemia (< 54 mg/dL; < 3 mmol/L), in target range (70-180 mg/dL; 3.9-10 mmol/L), and in hyperglycemia > 240 mg/dL; > 13.3 mmol/L)], frequency of self-monitoring of blood glucose, acute complications, skin reactions, and reasons for initiation/discontinuation.

RESULTS

Among patients with regular use of the FSL-CGM (n = 59), mean HbA1c decreased from 8.86 ± 0.23 to 8.05 ± 0.2% (73.3-64.5 mmol/mol) in 3 months (p = 0.0001) and plateaued thereafter. A clinically significant reduction in HbA1c (defined as a decrease of ≥ 0.5%) was associated with shorter diabetes duration. Of 71 patients who initiated use of the FSL-CGM, 12 (16.9%) discontinued during the study period. No statistically significant changes were found after FSL-CGM use, in mean and standard deviation IFG levels, and in time of glucose levels in target, hypoglycemia, and hyperglycemia ranges. One patient with hypoglycemia unawareness was found dead-in-bed while using FSL-CGM.

CONCLUSIONS

Real-life observational data in a self-selected young T1D population demonstrated a significant and sustained reduction in HbA1c with FSL-CGM in one-third of the participants. Surveillance of glucose monitoring should be individualized, especially for patients with hypoglycemia unawareness.

Accuracy, satisfaction and usability of a flash glucose monitoring system among children and adolescents with type 1 diabetes attending a summer camp

BACKGROUND

The study aimed to assess accuracy, satisfaction and usability of a flash glucose monitoring system (FGM) in children and adolescents with type 1 diabetes mellitus (T1DM) attending a diabetes summer camp.

METHODS

Sixty-six children and adolescents with T1DM aged 6 to 17 years participating in a 7-day medically supervised summer camp were enrolled. Capillary blood glucose (BG) and flash glucose (FG) values were measured simultaneously at breakfast, lunch, and dinner and for any given FG value <72 mg/dL (<4.0 mmol/L) during daytime, <108 mg/dL (<6.0 mmol/L) at nighttime, >270 mg/dL (>15.0 mmol/L) or when patient symptoms were discordant with sensor readings. Sensor-related issues were documented and patients' and healthcare professionals' (HCPs) satisfaction was evaluated.

RESULTS

FGM demonstrated satisfactory clinical accuracy compared to reference capillary BG values with 98.8% of values falling within the clinically acceptable zones (A and B) of the consensus error grid. Overall mean absolute relative difference (MARD) was 16.7% ± 16.1%. Specific calculations of mean absolute difference (MAD), mean relative difference (MRD), and mean difference (MD) demonstrated that FGM overestimated BG values across all glycemic ranges. Overall satisfaction with the FGM was high in 91.7% participants and 95.0% HCPs, although confidence in the system was low in 18.0% participants and 40.0% HCPs.

CONCLUSIONS

The FGM exhibited satisfactory clinical accuracy. However, based on the present data, we conclude that no decision should be taken on the basis of a single, non-verified, FGM value alone. Our study highlights the need for revised therapeutic education for patients/families and further investigation on the integration of sensor readings in clinical decision-making.

Evaluation of the FreeStyle® Libre Flash Glucose Monitoring System in Children and Adolescents with Type 1 Diabetes

BACKGROUND/AIMS

The FreeStyle® Libre Flash Glucose Monitoring System (FGM, Abbott) measures glucose concentrations in the interstitial fluid for up to 14 days. It has been approved for use in children aged > 4 years in January 2016. Experience in children is still limited. We evaluated the accuracy and usability of the FGM in children with type 1 diabetes mellitus (DM).

METHODS

67 children with type 1 DM (35 girls), aged 4-18 years, were included. Subjects wore a sensor on the back of their upper arm. For the first 14 days, they regularly measured capillary blood glucose (BG) with their usual BG meter (Accu-Chek® Mobile [ACM], Roche [n = 24]; Contour® Next Link [CNL], Bayer [n = 26]; OneTouch® Verio® IQ [OTV], LifeScan [n = 17]) followed by a sensor glucose (SG) scanning. SG readings were compared to BG measurements by consensus error grid (CEG) analysis; the mean difference (MD), the mean relative difference (MRD), the mean absolute difference (MAD), and the mean absolute relative difference (MARD) were calculated. After 14 days, subjects were asked to fill in a questionnaire on the usability of the FGM.

RESULTS

2,626 SG readings were paired with BG results. FGM readings were highly correlated with BG (r = 0.926, p < 0.001). 80.3% of the data pairs were in zone A (= no effect on clinical action) and 18.4% were in zone B (= altered clinical action with little or no effect on the clinical outcome) of the CEG. Overall MD was +7.5 mg/dL; MD varied with the BG meter: ACM +10.4 mg/dL, CNL +14.2 mg/dL, OTV -3.6 mg/dL (p < 0.001). Overall, MARD was 16.7%. We observed a large interindividual variability in the accuracy parameters. MD and MRD were inversely related to BMI (r = -0.261 [p < 0.05]; r = -0.266 [p < 0.05], respectively). MARD was inversely related to age (r = -0.266 [p < 0.05]). Twenty-nine patients (43.3%) reported sensor problems, mainly early detachment of the sensor. Nonetheless, the usability questionnaire indicated high levels of satisfaction.

CONCLUSIONS

Our results showed a reasonable agreement between the FGM SG readings and capillary BG measurements in children. There was, however, a large interindividual variability. The wearing of the sensor requires special attention. Further studies in children are imperative in order to document the accuracy and safety of the FGM in the paediatric population.

Longitudinal trends in HbA1c patterns and association with outcomes: A systematic review

BACKGROUND

This study aimed to review studies that identified patterns of longitudinal HbA1c trends in patients with diabetes and to summarize factors and outcomes associated with distinct trajectory patterns.

METHODS

PubMed and Web of Science were systematically searched for studies examining HbA1c trends among patients with diabetes from database inception through September 2017. Articles were included if they met the following inclusion criteria: (a) longitudinal study of subjects with diabetes only, (b) use of serial measurements of HbA1c , and (c) analysis of the trend of HbA1c using group-based trajectory approaches.

RESULTS

Twenty studies were included, 11 on type 1 diabetes and 9 on type 2 diabetes. These studies identified 2 to 6 HbA1c trajectory patterns. The most commonly identified patterns included stable HbA1c around 7.0% and at levels between 8.0% and 9.9%, which usually captured the HbA1c pattern among the majority of subjects in the study population. Unstable patterns identified included increasing HbA1c trend, decreasing HbA1c trend, and non-linear patterns. These patterns were associated with differential risk of disease outcomes, over and beyond single-point HbA1c measures. Age, gender, ethnicity, diabetes duration, disease management frequency, cardiovascular risk factors, insulin treatment, family environment, and psychosocial factors were the most frequently reported factors associated with membership of specific HbA1c pattern groups.

CONCLUSION

Common patterns of longitudinal HbA1c trends were identified despite heterogeneity among the studies. A better understanding of what underlies these different patterns may provide opportunities to tailor therapies and care for these patients to reduce adverse outcomes.

Metabolic control of type 1 diabetes in youth with autism spectrum disorder: A multicenter Diabetes-Patienten-Verlaufsdokumentation analysis based on 61 749 patients up to 20 years of age

BACKGROUND

A paucity of reports in the literature exists concerning the co-existence between autism spectrum disorder (ASD) and type 1 diabetes (T1D).

OBJECTIVE

To compare clinical characteristics, diabetes management and metabolic control in youth with T1D and ASD (T1D-ASD) with youth without ASD (T1D-non ASD).

METHODS

Using the German/Austrian diabetes patient follow-up registry, this study analyzed aggregated data from the last available year of observation for each patient with T1D, ages 1-20 with consistent data on insulin regimen and glycated hemoglobin (A1C), between January, 2005 and March, 2017.

RESULTS

From 61 749 patients, 150 (0.24%) were identified as T1D-ASD. Non-adjusted comparisons showed similar results for mean age at onset and duration of diabetes, but not for gender (male: T1D-ASD: 85.3%; T1D-non ASD: 52.8%; P < .001). Unadjusted comparisons showed no difference for severe hypoglycemia, diabetic ketoacidosis, insulin doses, insulin pump therapy, and body mass index. A statistical difference was observed for A1C (P-value .01) and in the number of blood glucose (SMBG) tests/day (median [interquartile range]: T1D-ASD 6.0 [4.4-7.0]; T1D-non ASD 5.0 [4.4-7.0]; P-value < .001). After adjusting for age, gender, duration of diabetes, and year of observation, only SMBG remained significant (P-value .003). T1D-ASD used psycho-stimulants (15.3% vs 2.2%; P-value < .001), antipsychotics (10.7% vs 0.6%; P-value < .001), and antidepressive medications (3.6% vs 0.7%; P-value < .001) more frequently.

CONCLUSION

Metabolic control was similar in the T1D-ASD group compared to T1D-non ASD despite their comorbidity. Awareness of ASD remains important in T1D treatment, as both conditions require long-term multi-disciplinary medical follow-up for optimal outcomes.

Technology in the management of type 1 diabetes mellitus - current status and future prospects

Type 1 diabetes mellitus (T1DM) represents 5-10% of diabetes cases worldwide. The incidence of T1DM is increasing, and there is no immediate prospect of a cure. As such, lifelong management is required, the burden of which is being eased by novel treatment modalities, particularly from the field of diabetes technologies. Continuous glucose monitoring has become the standard of care and includes factory-calibrated subcutaneous glucose monitoring and long-term implantable glucose sensing. In addition, considerable progress has been made in technology-enabled glucose-responsive insulin delivery. The first hybrid insulin-only closed-loop system has been commercialized, and other closed-loop systems are under development, including dual-hormone glucose control systems. This Review focuses on well-established diabetes technologies, including glucose sensing, pen-based insulin delivery, data management and data analytics. We also cover insulin pump therapy, threshold-based suspend, predictive low-glucose suspend and single-hormone and dual-hormone closed-loop systems. Clinical practice recommendations for insulin pump therapy and continuous glucose monitoring are presented, and ongoing research and future prospects are highlighted. We conclude that the management of T1DM is improved by diabetes technology for the benefit of the majority of people with T1DM, their caregivers and guardians and health-care professionals treating patients with T1DM.

Neonatal Diabetes Mellitus

Neonatal diabetes is a rare cause of hyperglycemia in the neonatal period. It is caused by mutations in genes that encode proteins playing critical roles in normal functions of pancreatic beta cells. Neonatal diabetes is divided into temporary and permanent subtypes. Treatment is based on the correction of fluid-electrolyte disturbances and hyperglycemia. Patients respond to insulin or sulfonylurea treatment according to the mutation type. Close glucose monitoring and education of caregivers about diabetes are vital.

Remote Lifestyle Coaching Plus a Connected Glucose Meter with Certified Diabetes Educator Support Improves Glucose and Weight Loss for People with Type 2 Diabetes

BACKGROUND

Connected health devices with lifestyle coaching can provide real-time support for people with type 2 diabetes (T2D). However, the intensity of lifestyle coaching needed to achieve outcomes is unknown.

METHODS

Livongo provides connected, two-way messaging glucose meters, unlimited blood glucose (BG) test strips, and access to certified diabetes educators. We evaluated the incremental effects of adding lifestyle coaching on BG, estimated HbA1c, and weight. We randomized 330 eligible adults (T2D, HbA1c > 7.5%, BMI ≥ 25) to receive no further intervention (n = 75), a connected scale (n = 115), scale plus lightweight coaching (n = 73), or scale plus intense coaching (n = 67) for 12 weeks. We evaluated the change in outcomes using ANOVA.

RESULTS

Livongo participation alone resulted in improved BG control (mean HbA1c declined: 8.5% to 7.5%, p = 0.01). Mean weight loss and additional BG decreases were higher in the intensive compared with the lightweight coaching and scale-only groups (weight change (lb): -6.4, -4.1, and -1.1, resp., p = 0.01; BG change (mg/dL): -19.4, -11.3, and -2.9, resp., p = 0.02). The estimated 12-week program costs were 5.5 times more for intensive than lightweight coaching.

CONCLUSION

Livongo participation significantly improves BG control in people with T2D. Additional lifestyle coaching may be a cost-effective intervention to achieve further glucose control and weight loss.

Time Savings Using a Standardized Glucose Reporting System and Ambulatory Glucose Profile

BACKGROUND

Diabetes care is predominately done at home by the patient. When clinics do not have a reliable, easy process for obtaining this patient data, clinical decisions must be made with incomplete verbal recall reports. Unused or inaccessible glucose data represent a large information gap affecting clinical decision making. This study's purpose was to design an optimized glucose device download system with a standardized report and to evaluate its efficiency.

METHODS

Observations and evaluations of glucose data retrieval occurred at two clinics; an additional clinic utilized the optimized process doing only post process timings. Patients/families and clinicians were surveyed about their experiences with the system and the standardized report (AGP). The study was approved by all the sites' IRBs.

RESULTS

Optimized systems saved staff at least 3 min per patient. Standardized AGP reports and an optimized data system made the work flow of glucose data easier to complete. The AGP report was preferred by patients, families, and clinicians.

CONCLUSIONS

An optimized system takes advantage of patient lobby downtime to download glucose devices and ensures that diabetes clinical decisions are made utilizing all available data. Staff and patients liked the software lobby system and found it a valuable time-saving tool.

Diabetes in Childhood and Adolescence

BACKGROUND

The incidence of type 1 diabetes mellitus in childhood and adolescence is steadily rising and now stands at 22.9 new cases per year per 100 000 persons up to age 15.

METHODS

This review is based on pertinent publications retrieved by a selective literature search, with special attention to the current German S3 guideline on diabetes in childhood and adolescence.

RESULTS

Polydipsia, polyuria, and weight loss are the characteristic presenting symptoms of diabetes mellitus. The acutely presenting patient needs immediate stabilization because of the danger of rapid metabolic decompensation (risk of keto - acidosis, 21.1%). Long-term insulin therapy can be delivered either by subcutaneous injection or by an insulin pump. The goals of treatment are the near-normalization of glucose metabolism (HbA1c <7.5%), the avoidance of acute complications (hypoglycemia and ketoacidosis), the reduction of diabetes-specific sequelae (retinopathy, nephropathy, neuropathy, hypertension, and hyperlipidemia), unrestricted participation in age-appropriate everyday activities, and normal physical and psychosocial development. Children and adolescents with diabetes need individualized treatment with frequent adjustments and holistic overall care so that these goals can be effectively met.

CONCLUSION

Every physician must be able to diagnose the initial presentation of diabetes and to initiate the first steps in its management. The patient should be referred as soon as possible to a diabetes team that has experience in the treatment of children and adolescents.

Inequalities in glycaemic control, hypoglycaemia and diabetic ketoacidosis according to socio-economic status and area-level deprivation in Type 1 diabetes mellitus: a systematic review

AIM

The aim of this systematic review was to examine the associations of individual-level as well as area-level socio-economic status and area-level deprivation with glycaemic control, hypoglycaemia and diabetic ketoacidosis in people with Type 1 diabetes mellitus.

METHODS

Ovid MEDLINE was searched to identify relevant cohort, case-control or cross-sectional studies published between January 2000 and June 2015. Search results were screened by title, abstract and keywords to identify eligible publications. Decisions on inclusion or exclusion of full texts were made independently by two reviewers. The Newcastle-Ottawa Scale was used to estimate the methodological quality of included studies. Quality assessment and extracted data of included studies were synthesized narratively and reported according to the PRISMA statement.

RESULTS

Literature search in Ovid MEDLINE identified 1345 eligible studies. Twenty studies matched our inclusion and exclusion criteria. Two articles were additionally identified through hand search. According to the Newcastle-Ottawa Scale, most of the studies were of average quality. Results on associations of socio-economic status and area-level deprivation with glycaemic control and hypoglycaemia were contradictory between studies. By contrast, lower socio-economic status and higher area-level deprivation were associated with a higher risk for diabetic ketoacidosis in all except one study.

CONCLUSIONS

Lower socio-economic status and higher area-level deprivation are associated with a higher risk of experiencing diabetic ketoacidosis in people with Type 1 diabetes mellitus. Access to care for socially deprived people needs to be expanded to overcome impairing effects on the course of the condition and to reduce healthcare disparities.

6. Glycemic Targets: Standards of Medical Care in Diabetes-2018

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Does knowledge on diabetes management influence glycemic control? A nationwide study in patients with type 1 diabetes in Brazil

OBJECTIVE

The purpose of this study is to establish demographic and clinical data associated with the knowledge on diabetes management and its influence on glycemic control in patients with type 1 diabetes.

METHODS

This was a retrospective, observational, multicenter study conducted with 1,760 patients between August 2011 and August 2014 in 10 cities of Brazil.

RESULTS

Overall, 1,190 (67.6%) patients knew what glycated hemoglobin (HbA1c) means. These patients were older, had longer disease duration, longer follow-up in each center, reported lower frequency of self-reported hypoglycemia, and were more frequently Caucasians and at glycemic goal. Multivariate analysis showed that knowledge on what HbA1c means was related to more years of school attendance, self-reported ethnicity (Caucasians), severe hypoglycemia, economic status, follow-up time in each center, and participation on diabetes educational programs. Good glycemic control was related to older age, more years of school attendance, higher frequency of daily self-monitoring of blood glucose, higher adherence to diet, and knowledge on what HbA1c means.

CONCLUSION

Patients with a knowledge on what HbA1c means had a better chance of reaching an adequate glycemic control that was not found in the majority of our patients. Diabetes care teams should rethink the approaches to patients and change them to more proactive schedules, reinforcing education, patients' skills, and empowerment to have positive attitudes toward reaching and maintaining a better glycemic control. Finally, the glucocentric approach to diabetes management should be changed to actions that include patients' psychosocial aspects aiming to reduce the stress of living with diabetes, improving glycemic control, and avoiding adverse outcomes.

Flash Glucose Measurements in Children with Type 1 Diabetes in Real-Life Settings: To Trust or Not to Trust?

BACKGROUND AND AIMS

To evaluate the clinical accuracy of a flash glucose monitoring device FreeStyle Libre (FSL) among children with type 1 diabetes in real-world settings during a summer camp.

MATERIALS AND METHODS

During a summer camp, children with type 1 diabetes (n = 79, aged 8-18 years) were provided with FSLs for 12 days. On days 3, 7, and 11 of the study, they underwent supervised glucose testing at 8 timepoints. Glycemia was estimated by using FSL and measured with a personal glucometer within a period of 2 min. The glucose trend arrows were recorded.

RESULTS

The study was completed by 78 children (median: age 12.8 years, diabetes duration 5.8 years, HbA1c 58.5 mmol/mol). Mean absolute relative difference (MARD) between the FSL and the glucometer was 13.5% ± 12.9%. FSL was the most accurate in stable glycemic conditions: MARD 11.4% ± 10.4%, less accurate when glycemia was falling >2 mg/(dL·min) [0.111 mmol/(L·min)-MARD 22.6% ± 18.6%; P < 0.001 vs. stable conditions] and when the device could not determine the glucose trends (16.5% ± 16.3%, P = 0.01 vs. stable conditions). The FSL demonstrated lower accuracy during the day than the night [MARD 14.9% ± 14% vs. 11.2% ± 10.6%, P < 0.0001]. Out of 1655 data pairs of glucometer and FSL, using the Surveillance Error Grid methodology we determined that 80.36% of FSL readings were associated with no clinical risk, 18.73% with slight risk and only one high-risk measurement was detected.

CONCLUSION

FSL is accurate in children, but its accuracy depends on the glucose trend. Results flagged by the rapid fall flag and "trend undetermined" should be verified by blood glucose measurements.

Factors associated to adherence to blood glucose self-monitoring in patients with diabetes treated with insulin. The dapa study

OBJECTIVE

To assess adherence to self-monitoring of blood glucose and the main factors associated with it, particularly those related to self-perception of glycemia, in patients with diabetes on insulin therapy.

PATIENTS AND METHODS

An epidemiological, observational, prospective, multicenter study conducted in standard clinical practice in primary care, outpatient centers, and hospitals from different Spanish regions. Sociodemographic, clinical and treatment data were collected. Patients were considered adherent to self-monitoring if they performed the minimum number of controls recommended by the Spanish Society of Diabetes (SED).

RESULTS

Adherence was shown in 61.6% of patients. Factors associated to adherence included treatment with less than three insulin injections daily (OR 2.678; 95% CI 2.048- 3.5029; p <0.001), presence of peripheral vascular disease (OR 1.529; 95% CI 1.077 - 2.171; p=0.018), alcohol abstinence (OR 1.442; 95% CI 1.118 - 1.858; p=0.005), and collection of the glucose test strips from the pharmacy (OR 1.275; 95% CI 1.026 - 1.584; p=0.028). Adequate self-perception of glycemia was found in 21.4% of patients.

CONCLUSIONS

Our results show a suboptimal adherence to the recommended protocol for blood glucose self-monitoring in patients with diabetes on insulin therapy. Independent variables associated to good adherence were treatment with less than three insulin injections dailyu, presence of peripheral vascular disease, alcohol abstinence, and collection of glucose test strips from the pharmacy.

Both the frequency of HbA1c testing and the frequency of self-monitoring of blood glucose predict metabolic control: A multicentre analysis of 15 199 adult type 1 diabetes patients from Germany and Austria

BACKGROUND

The objective of this study was to examine the association between metabolic control and frequency of haemoglobin A_1c (HbA_1c ) measurements and of self-monitoring of blood glucose, as well as the interaction of both.

METHODS

Data of 15 199 adult type 1 diabetes patients registered in a standardized electronic health record (DPV) were included. To model the association between metabolic control and frequency of HbA_1c testing or of self-monitoring of blood glucose, multiple hierarchic regression models with adjustment for confounders were fitted. Tukey-Kramer test was used to adjust P values for multiple comparisons. Vuong test was used to compare non-nested models.

RESULTS

The baseline variables of the study population were median age 19.9 [Q1; Q3: 18.4; 32.2] years and diabetes duration 10.4 [6.8; 15.7] years. Haemoglobin A_1c was 60.4 [51.5; 72.5] mmol/mol. Frequency of HbA_1c testing was 8.0 [5.0; 9.0] within 2 years, and daily self-monitoring of blood glucose frequency was 5.0 [4.0; 6.0]. After adjustment, a U-shaped association between metabolic control and frequency of HbA_1c testing was observed with lowest HbA_1c levels in the 3-monthly HbA_1c testing group. There was an inverse relationship between self-monitoring of blood glucose and HbA_1c with lower HbA_1c associated with highest frequency of testing (>6 daily measurements). Quarterly HbA_1c testing and frequent self-monitoring of blood glucose were associated with best metabolic control. The adjusted Vuong Z statistic suggests that metabolic control might be better explained by HbA_1c testing compared to self-monitoring of blood glucose (P < .0001).

CONCLUSION

This research reveals the importance of quarterly clinical HbA_1c monitoring together with frequent self-monitoring of blood glucose in diabetes management to reach and maintain target HbA_1c .

Clinical and Psychosocial Factors Associated With Suicidal Ideation in Adolescents With Type 1 Diabetes

PURPOSE

This study delineates clinical and psychosocial characteristics of adolescents with type 1 diabetes and suicidal ideation (SI) and reports clinical and psychosocial outcomes after mental health intervention (safety assessment and brief in-clinic intervention).

METHODS

Adolescents aged 13-17 years with type 1 diabetes completed the Children's Depression Inventory (CDI) from January 2011 to 2012. Youth with significant depressive symptoms and/or SI endorsement underwent mental health intervention. Two control subjects were matched to each adolescent endorsing SI and compared using t-tests to assess clinical and psychosocial variables. Trajectory of depressive symptoms and outcomes for case subjects were observed through January 2013.

RESULTS

Twenty-seven percent (127/473) exhibited moderate to high risk for depression based on CDI scores and 38 (8%) endorsed SI. Adolescents who endorsed SI were more likely to have higher CDI scores and public insurance when compared with youth who denied SI. There was no difference in glycemic control, measured by hemoglobin A1c, between case and control groups. During the year after intervention, 28 participants who initially endorsed SI underwent repeat assessment; mean CDI scores declined by 10.57 (standard deviation: 6.92) points and 78% no longer endorsed SI.

CONCLUSIONS

Given the potential lethality of insulin when taken in intentional overdose, the need for consistent identification of suicidality is an important feature of depression screening. Study findings indicate statistically significant differences in depressive symptoms and insurance status, when comparing adolescents who endorsed SI to those who denied. Improvement in depressive symptoms and SI endorsement occurred after integrating brief mental health intervention into diabetes visits.

Factors associated with greater benefit of a national reimbursement policy for blood glucose test strips in adult patients with type 1 diabetes: A prospective cohort study

AIMS/INTRODUCTION

We aimed to identify factors independently associated with greater benefit of a national reimbursement policy for blood glucose test strips in adult patients with type 1 diabetes, in terms of glycemic control and the rate of severe hypoglycemia.

MATERIALS AND METHODS

This was a prospective cohort study of 466 adult patients with type 1 diabetes from five tertiary referral hospitals who registered for a national reimbursement program for blood glucose strips and were then followed-up for 12 months. Factors associated with a > 5% reduction in glycated hemoglobin (HbA1c) and decreased rate of severe hypoglycemia (SH) at 12 months from baseline were evaluated.

RESULTS

At the end of the 12 months of follow up, 158 of 466 patients (33.9%) achieved >5% reduction in HbA1c, and 47 of 111 patients (42.3%) had a decreased rate of SH relative to baseline. Higher HbA1c (P < 0.001), lower total daily insulin dose at baseline (P = 0.048) and an increase in self-monitoring of blood glucose (SMBG) frequency during follow up (P = 0.001) were independently associated with >5% reduction in HbA1c. A higher SMBG frequency (P < 0.001), higher rate of SH at baseline (P = 0.029) and lack of hypoglycemic unawareness (P = 0.044) were independently associated with an increase in the frequency of SMBG during follow up. Higher SMBG frequency at baseline (P < 0.001) was independently associated with a decreased rate of SH.

CONCLUSIONS

Several factors, including higher SMBG frequency at baseline, were independently associated with reduced HbA1c and a decreased rate of severe hypoglycemia, showing that patients with these characteristics derive the most benefit from reimbursement of blood glucose test strips.

Use of a Connected Glucose Meter and Certified Diabetes Educator Coaching to Decrease the Likelihood of Abnormal Blood Glucose Excursions: The Livongo for Diabetes Program

Background

The Livongo for Diabetes Program offers members (1) a cellular technology-enabled, two-way messaging device that measures blood glucose (BG), centrally stores the glucose data, and delivers messages back to the individual in real time; (2) unlimited BG test strips; and (3) access to a diabetes coaching team for questions, goal setting, and automated support for abnormal glucose excursions. The program is sponsored by at-risk self-insured employers, health plans and provider organizations where it is free to members with diabetes or it is available directly to the person with diabetes where they cover the cost.

Objective

The objective of our study was to evaluate BG data from 4544 individuals with diabetes who were enrolled in the Livongo program from October 2014 through December 2015.

Methods

Members used the Livongo glucose meter to measure their BG levels an average of 1.8 times per day. We estimated the probability of having a day with a BG reading outside of the normal range (70-180 mg/dL, or 3.9-10.0 mmol/L) in months 2 to 12 compared with month 1 of the program, using individual fixed effects to control for individual characteristics.

Results

Livongo members experienced an average 18.4% decrease in the likelihood of having a day with hypoglycemia (BG <70 mg/dL) and an average 16.4% decrease in hyperglycemia (BG >180 mg/dL) in months 2-12 compared with month 1 as the baseline. The biggest impact was seen on hyperglycemia for nonusers of insulin. We do not know all of the contributing factors such as medication or other treatment changes during the study period.

Conclusions

These findings suggest that access to a connected glucose meter and certified diabetes educator coaching is associated with a decrease in the likelihood of abnormal glucose excursions, which can lead to diabetes-related health care savings.

Incidence of diabetes-related complications in Chinese patients with type 1 diabetes: a population-based longitudinal cohort study in Taiwan

OBJECTIVE

To estimate the incidence densities and cumulative incidence of diabetes-related complications in patients with type 1 diabetes for a maximum of 15-year follow-up. The estimations were further stratified by gender and age at diagnosis (ie, early onset: 0-12 years, late onset:≥13 years).

DESIGN

A population-based retrospective longitudinal cohort study.

SETTING

Taiwan's National Health Insurance medical claims.

PARTICIPANTS

4007 patients newly diagnosed with type 1 diabetes were identified during 1999-2012.

OUTCOME MEASURES

Acute complications included diabetic ketoacidosis (DKA) and hypoglycaemia. Chronic complications were cardiovascular diseases (CVD), retinopathy, neuropathy and nephropathy.

RESULTS

The incidence density of retinopathy was greatest (97.74 per 1000 person-years), followed by those of nephropathy (31.36), neuropathy (23.93) and CVD (4.39). Among acute complications, the incidence density of DKA was greatest (121.11 per 1000 person-years). The cumulative incidences of acute complications after 12 years following diagnosis were estimated to be 52.1%, 36.1% and 4.1% for DKA, outpatient hypoglycaemia and hospitalised hypoglycaemia, respectively. For chronic complications, the cumulative incidence of retinopathy after 12 years following diagnosis was greatest (65.2%), followed by those of nephropathy (30.2%), neuropathy (23.7%) and CVD (4.1%). Females with late-onset diabetes were greatly affected by advanced retinopathy (ie, sight-threatening diabetic retinopathy) and hospitalised hypoglycaemia, whereas those with early-onset diabetes were more vulnerable to DKA. Chronic complications were more commonly seen in late-onset diabetes, whereas early-onset diabetes were most affected by acute complications.

CONCLUSIONS

Ethnic Chinese patients with type 1 diabetes were greatly affected by DKA and retinopathy. The incidence of diabetes-related complications differed by age at diagnosis and sex.

Sleep duration and its impact on adherence in adolescents with type 1 diabetes mellitus

BACKGROUND

Adherence to the type 1 diabetes (T1D) regimen, while predictive of glycemic control, decreases during adolescence. For adolescents, attaining adequate sleep is an additional challenge. This study evaluates the impact of sleep on adherence in teens with T1D.

SUBJECTS

Forty-five adolescents aged 12-18 yr, with T1D for at least 6 months while on insulin pump therapy.

METHODS

Adolescents logged their sleep on a written diary for 2 wk. Corresponding insulin pump/glucometer downloads as well as sleep habit questionnaires were also obtained.

RESULTS

Data from 20 girls and 25 boys, with a mean age of 15 ± 1.6 yr and mean glycated hemoglobin of 8.7 ± 1.1% (72 mmol/mol), were analyzed. Overall, average sleep was 8.6 ± 0.9 h per night. Sleep durations were compared to the next day's frequency of self-monitored blood glucose (SMBG) and total daily insulin bolus frequency. Associations were found between sleep duration and youths' SMBG and insulin bolus frequencies (p < 0.03 and p < 0.001, respectively). Specifically, a 15- and 20-min increase in sleep was associated with one additional SMBG check and one additional insulin bolus, respectively.

CONCLUSION

Analyses suggest an associated increase in T1D self-management behaviors in youths with increased sleep duration. These findings highlight the importance of assessing sleep in clinical practice, and encourage further research to examine effective strategies to address sleep hygiene as part of routine diabetes management.

Impact of Self-monitoring of Blood Glucose Log Reliability on Long-term Glycemic Outcomes in Children with Type 1 Diabetes

INTRODUCTION

Logbooks of self-monitoring of blood glucose (SMBG) are useful in the modulation of insulin regimens, which aid in achieving glycemic control in type 1 diabetes mellitus (T1DM). However, discrepancies in SMBG charting may impede its utility. This study aimed to assess the accuracy of log entries and its impact on long-term glycemic control.

METHODS

SMBG in logbooks was compared with readings in glucometer memory and discrepancies between the two were evaluated in 101 children with T1DM. The relationship between these discrepancies and glycated hemoglobin (HbA1c) over 44 months was assessed.

RESULTS

Errors in glucose charting were observed in 32.67% children. The most common observed error was omission (42.42%), followed by fabrication (27.27%), erroneous (18.18%), and others (12.12%). Age was not significantly different among children having accurate versus inaccurate SMBG logs. During follow-up of 44 months, children with accurate SMBG logs consistently had lower HbA1c as compared to children having inaccurate logs, which was statistically significant at 4, 16, 20, and 28 months' follow-up. The same was reflected in the proportion of children achieving HbA1c <7% and 7%-9%. Of the 14 children who had omissions, 9 had omission of high values only, 3 patients had omission of low values only, 1 had omission of both high and low values, and 1 had omission of normal values. Among logs with fabrication, parents were responsible in 2 of 9 incidents. In the remaining 7, it was the child himself/herself. Children with fabrication consistently had the highest HbA1c values among the different types of inaccurate blood glucose chartings, which was statistically significant at 32 and 36 months of follow-up.

CONCLUSIONS

Reliability of SMBG logs is a significant problem among children with T1DM at our center. Children with accurate logs of SMBG readings were more likely to have better glycemic control on long-term follow-up.

Young patients with type 1 diabetes poorly controlled and poorly compliant with self-monitoring of blood glucose: can technology help? Results of the i-NewTrend randomized clinical trial

AIMS

To compare iBGStar™ + DMApp (experimental meter + telemedicine system) (iBGStar) with a traditional glucose meter (Control) in type 1 diabetes adolescents/young adults.

METHODS

i-NewTrend was a multicenter, open-label, randomized trial involving subjects aged 14-24 years, on basal-bolus insulin, HbA1c ≥ 8.0%, and poorly compliant with SMBG (i.e., <30% of the recommended frequency). Primary end points were change in HbA1c and achievement of compliance with SMBG (≥30% of the recommended frequency) after 6 months. Quality of life was also evaluated. A post-trial observational phase was conducted, where both groups used the experimental device.

RESULTS

Of 182 randomized patients (51.1% male; age 17.7 ± 3.0 years; diabetes duration 8.8 ± 4.7 years; HbA1c levels 10.0% ± 1.4), 92 were allocated to iBGStar and 90 to Control; 6.5% in iBGStar and 8.9% in Control dropped-out. After 6 months, HbA1c changes (±SE) were -0.44% ± 0.13 in iBGStar and -0.32% ± 0.13 in Control (p = 0.51). In the post-trial phase, HbA1c changes from 6 months (±SE) were -0.07% ± 0.14 in iBGStar and -0.31% ± 0.14 in Control (p = 0.24). Compliance end point was reached by 53.6% in iBGStar and 55.0% in Control (p = 0.86). Mean daily SMBG measurements increased from 1.1 to 2.3 in both groups without worsening quality of life. Compliant subjects showed a greater reduction in HbA1c levels (-0.60% ± 0.23 in iBGStar; -0.41% ± 0.21 in Control; p = 0.31). Within iBGStar group, telemedicine users (38.0%) reduced HbA1c by -0.58 ± 0.18.

CONCLUSIONS

iBGStar was not superior to the traditional meter. Irrespective of the strategy, increasing from 1 to 2 SMBG tests/day was associated with HbA1c reduction in both groups, without pharmacologic interventions. Identifying new technologies effective and acceptable to patients is an option to improve adherence to diabetes care.

TRIAL REGISTRATION

The trial was registered at ClinicalTrials.gov (registration number NCT02073188).

Behavioral Analysis of Chinese Adult Patients with Type 1 Diabetes on Self-monitoring of Blood Glucose

BACKGROUND

The information-motivation-behavioral skills (IMB) model of health behavior is an effective tool to evaluate the behavior of diabetes self-management. The purpose of this study was to explore behavioral factors affecting the practice of self-monitoring of blood glucose (SMBG) within the frame of IMB model of health behavioral among adult patients with type 1 diabetes in a single diabetes clinic in China.

METHODS

A questionnaire with three subscales on SMBG information, motivation, and behavioral skills based on IMB model was developed. Validity and reliability of the measures were examined and guaranteed. Adult patients with type 1 diabetes visiting our diabetes clinic from January to March 2012 (n = 55) were consecutively interviewed. The self-completion questionnaires were administered and finished at face-to-face interviews among these patients. Both descriptive and correlational analyses were made.

RESULTS

Fifty-five patients finished the questionnaires, with the median duration of diabetes 4.5 years and the median of SMBG frequency 2.00. Specific SMBG information deficits, motivation obstacles, and behavioral skill limitations were identified in a substantial proportion of participants. Scores of SMBG motivation (r = 0.299, P= 0.026) and behavioral skills (r = 0.425, P= 0.001) were significantly correlated with SMBG frequency. The multiple correlation of SMBG information, SMBG motivation, and SMBG behavioral skills with SMBG frequency was R = 0.411 (R2 = 0.169, P= 0.023).

CONCLUSIONS

Adult patients with type 1 diabetes in our clinic had substantial SMBG information deficits, motivation obstacles, and skill limitations. This information provided potential-focused education targets for diabetes health-care providers.

Longitudinal Trajectories of Metabolic Control From Childhood to Young Adulthood in Type 1 Diabetes From a Large German/Austrian Registry: A Group-Based Modeling Approach

OBJECTIVE

Worsening of glycemic control in type 1 diabetes during puberty is a common observation. However, HbA_1c remains stable or even improves for some youths. The aim is to identify distinct patterns of glycemic control in type 1 diabetes from childhood to young adulthood.

RESEARCH DESIGN AND METHODS

A total of 6,433 patients with type 1 diabetes were selected from the prospective, multicenter diabetes patient registry Diabetes-Patienten-Verlaufsdokumentation (DPV) (follow-up from age 8 to 19 years, baseline diabetes duration ≥2 years, HbA_1c aggregated per year of life). We used latent class growth modeling as the trajectory approach to determine distinct subgroups following a similar trajectory for HbA_1c over time.

RESULTS

Five distinct longitudinal trajectories of HbA_1c were determined, comprising group 1 = 40%, group 2 = 27%, group 3 = 15%, group 4 = 13%, and group 5 = 5% of patients. Groups 1-3 indicated stable glycemic control at different HbA_1c levels. At baseline, similar HbA_1c was observed in group 1 and group 4, but HbA_1c deteriorated in group 4 from age 8 to 19 years. Similar patterns were present in group 3 and group 5. We observed differences in self-monitoring of blood glucose, insulin therapy, daily insulin dose, physical activity, BMI SD score, body-height SD score, and migration background across all HbA_1c trajectories (all P ≤ 0.001). No sex differences were present. Comparing groups with similar initial HbA_1c but different patterns, groups with higher HbA_1c increase were characterized by lower frequency of self-monitoring of blood glucose and physical activity and reduced height (all P < 0.01).

CONCLUSIONS

Using a trajectory approach, we determined five distinct longitudinal patterns of glycemic control from childhood to early adulthood. Diabetes self-care, treatment differences, and demographics were related to different HbA_1c courses.

Effect of carbohydrate counting using bolus calculators on glycemic control in type 1 diabetes patients during continuous subcutaneous insulin infusion

The present study examined the long‐term efficacy of insulin pump therapy for type 1 diabetes patients when carried out using carbohydrate counting with bolus calculators for 1 year. A total of 22 type 1 diabetes patients who had just started continuous subcutaneous insulin infusion were examined and divided into two groups: one that was educated about carbohydrate counting using bolus calculators (n = 14); and another that did not use bolus calculators (n = 8). After 1 year, the hemoglobin A1c levels of the patient group that used bolus calculators decreased persistently and significantly (P = 0.0297), whereas those of the other group did not. The bodyweight, total daily dose of insulin and bolus percentage of both groups did not change. Carbohydrate counting using bolus calculators is necessary to achieve optimal and persistent glycemic control in patients undergoing continuous subcutaneous insulin infusion.

Boluses in Insulin Therapy

Giving a bolus is one major part in multiple dose insulin therapy (MDI) along with basal insulin substitution. To adjust the bolus optimally, different factors like carbohydrate content and composition of the meal, correction factors, and timing have to be considered. Advances in technologies like bolus advisors can assist the patients but still there a several open questions and technical challenges regarding boluses. This commentary provides an opportunity to address several of the above-mentioned factors influencing the result of bolusing. It shall draw attention to those factors and address the current opportunities, for example, continuous subcutaneous insulin infusion (CSII), as well as the need for further studies which can help to improve diabetes insulin therapy by means of the correct use of boluses.

Clinical review: the misreporting of logbook, download, and verbal self-measured blood glucose in adults and children with type I diabetes

Despite advances in technology, the frequent self-measurement of blood glucose (SMBG) remains fundamental to the management of 1 diabetes mellitus (T1DM). Once measured, SMBG results are routinely reported back to health professionals and other interested parties, either verbally, via a logbook, or electronically downloaded from a pump or meter. The misreporting of SMBG using various techniques represents a classic non-adherence behavior and carries with it both acute and chronic dangers. In addition, while this behavior appears very prevalent, many aspects remain largely unstudied. With this in mind, we aimed to summarize literature addressing the misreporting of SMBG in T1DM via a detailed literature search. This produced both recent and past literature. While most of these studies examined the prevalence of deliberate misreporting in a verbal or logbook context, others focused on the motivations behind this behavior, and alternative forms of misreporting, including deliberate manipulation of meters to produce inaccurate results and true technological errors. This timely review covers all aspects of misreporting and highlights multiple patient techniques, which are clearly adapting to advances in technology. We believe that further understanding and attention to this aspect of adherence may lead not only to improvements in glycemic control and safety, but also to the psychological well-being of those affected by type 1 diabetes.

Adherence of self-monitoring of blood glucose in persons with type 1 diabetes in Sweden

OBJECTIVE

The primary aim was to evaluate the extent to which persons with type 1 diabetes perform self-monitoring of blood glucose (SMBG) according to guidelines. Secondary objectives were to investigate predictors for good SMBG adherence, reasons for non-adherence, and association between SMBG frequency and hemoglobin A1c (HbA1c).

METHODS

This was a survey-based cross-sectional study. Questionnaires were sent out to 600 random patients at five sites. Patients were included if they were diagnosed with type 1 diabetes and ≥18 years old and excluded if they were currently using continuous glucose monitoring (CGM). Analysis of data was performed separately for the three sites where the answer frequency was ≥70%.

RESULTS

In total, 138 of 314 study participants, 43.9% (95% CI 38.5% to 49.4%) performed SMBG ≥4 times per day. For the three clinics where ≥70% of surveyed patients were included in the analysis, results were similar, 41.3% (95% CI 34.7% to 47.8%). Top three reported reasons for not performing more frequent SMBG were lack of time, not remembering, and self-consciousness. Frequency of SMBG was associated with HbA1c levels (p<0.0001). 30% of patients believed that ≤3 SMBG/day was recommended by healthcare providers.

CONCLUSIONS

Less than 50% of patients in Sweden follow guidelines of SMBG ≥4 times per day, despite glucose meters and strips being generally available at no cost. This indicates a need for further support in performing SMBG and increased availability of other tools for glucose monitoring.

Interaction of Pubertal Development and Metabolic Control in Adolescents with Type 1 Diabetes Mellitus

BACKGROUND

In T1DM, delayed pubertal development and reduced final height are associated with inadequate metabolic control.

OBJECTIVE

To assess whether T1DM affects pubertal growth spurt and whether metabolic control during puberty is gender-related.

METHODS

Using a large multicentre database, longitudinal data from 1294 patients were analysed. Inclusion criteria: complete records of height and HbA1c from the age of seven to 16 years. Exclusion criteria: other significant chronic diseases and medications, T1DM duration less than three months, and initial BMI < 3rd or >97th percentile.

RESULTS

Growth velocity (GV) was impaired with a significant reduction of peak GV by 1.2 cm in boys. HbA1c increase during male puberty was lower except for a period of 1.5 years. The highest HbA1c increase in boys coincided with maximum growth spurt. In girls, the highest HbA1c increase was observed during late puberty. Even though there is impaired GV, both sexes reach a height at 16 years of age which corresponds to the background population height.

CONCLUSION

Worsening of metabolic control is sex-discordant and associated with gender-specific alterations of GV. However, the vast majority of boys and girls with T1DM seems to reach normal height at the age of 16 years.

Head-to-head comparison between flash and continuous glucose monitoring systems in outpatients with type 1 diabetes

PURPOSE

Continuous glucose monitoring (CGM) is being increasingly used in clinical practice. The flash glucose monitoring (FGM) and CGM are different systems of interstitial glucose recording. We aimed to determine the agreement between the factory-calibrated FGM FreeStyle Libre (FSL) and the gold-standard CGM Dexcom G4 Platinum (DG4P).

METHODS

We analyzed data from n = 8 outpatients with type 1 diabetes, who wore the FSL and DG4P for up to 14 days during their habitual life. We aligned FSL and DG4P recordings to obtain paired glucose measures. We calculated correlation coefficients, mean absolute relative difference (MARD), percentages in Clarke error grid areas, time spent in hyperglycaemia, target glycaemia, or hypoglycaemia, as well as glucose variability with both sensors. Comparison with self-monitoring of blood glucose (SMBG) was also performed.

RESULTS

Patients varied in terms of age, diabetes duration, and HbA1c (from 5.9 to 9.6 %). In the pooled analysis of 10,020 paired values, there was a good correlation between FSL and DG4P (r ² = 0.76; MARD = 18.1 ± 14.8 %) with wide variability among patients. The MARD was significantly higher during days 11-14 than in days 1-10, and during hypoglycaemia (19 %), than in normoglycaemia (16 %) or hyperglycaemia (13 %). Average glucose profiles and MARD versus SMBG were similar between the two sensors. Time spent in normo-, hyper-, or hypoglycaemia, and indexes of glucose variability was similarly estimated by the two sensors.

CONCLUSIONS

In outpatients with type 1 diabetes, we found good agreement between the FSL and DG4P. No significant difference was detected in the estimation of clinical diagnostic parameters.

Frequent use of an automated bolus advisor improves glycemic control in pediatric patients treated with insulin pump therapy: results of the Bolus Advisor Benefit Evaluation (BABE) study

BACKGROUND

The relationship between frequency and sustained bolus advisor (BA) use and glycemic improvement has not been well characterized in pediatric populations.

OBJECTIVE

The objective of this study is to assess the impact of frequent and persistent BA use on glycemic control among pediatric type 1 diabetes patients.

METHODS

In this 6-month, single-center, retrospective cohort study, 104 children [61 girls, mean age: 12.7 yr, mean HbA1c 8.0 (1.6)% [64 (17.5) mmol/mol]], treated with the Accu-Chek Aviva Combo insulin pump, were observed. Frequency of BA use, HbA1c, hypoglycemia (<70 mg/dL), therapy changes, mean blood glucose, and glycemic variability (standard deviation) was assessed at baseline and month 6. Sub-analyses of the adolescent patient use (12 months) and longitudinal use (24 months) were also conducted.

RESULTS

Seventy-one patients reported high frequency (HF) device use (≥50%); 33 reported low frequency (LF) use (<50%) during the study. HF users achieved lower mean (SE) HbA1c levels than LF users: 7.5 (0.1)% [59 (1.1) mmol/mol] vs. 8.0 (0.2)% [64 (2.2) mmol/mol], p = 0.0252. No between-group differences in the percentage of hypoglycemia values were seen at 6 months. HF users showed less glycemic variability (84.0 vs. 94.7, p = 0.0045) than LF users. More HF patients reached HbA1c target of <7.5 at 6 months 66.2% (+16.9) vs. 27.3% (-9.1), p = 0.0056. Similar HbA1c results were seen in adolescents and BA users at 24 months.

CONCLUSION

Frequent use of the Accu-Chek Aviva Combo insulin pump BA feature was associated with improved and sustained glycemic control with no increase in hypoglycemia in this pediatric population.

Exploring the motivations behind misreporting self-measured blood glucose in adolescents with type 1 diabetes - a qualitative study

Background

Despite advances in diabetes management, the reporting and self-monitoring of blood glucose (SMBG) remains fundamental. While previous work has established that the misreporting of SMBG to family and medical professionals is surprisingly common, the motivations behind this behaviour have never been examined. We aimed to investigate the motivations behind misreporting of SMBG in adolescents with type 1 diabetes (T1DM).

Methods

Fifteen semi-structured interviews were conducted with adolescents (aged 12–19 inclusive) with T1DM recruited through diabetes clinics across the Otago/Southland region of New Zealand from November 2015 to January 2016. These were transcribed and content analysis performed to identify themes and subthemes in misreporting behaviour.

Results

The mean age of participants was 15.7 years, 60 % were male, with 67 % using multiple daily insulin injections, and 33 % on insulin pumps. Their median HbA1c was 84 mmol/mol, range 52–130. Misreporting behaviour was described for both electronic pump records and written logbooks, as well as verbally. Multiple motivations for misreporting were given, spanning three major themes: Achieving potential benefits; the avoidance of negative consequences; and the avoidance of worry/concern (in self or in others). The main suggestion of participants to reduce misreporting behaviour was to reduce the negative reactions of others to suboptimal blood glucose readings.

Conclusion

Electronic, written, and verbal SMBG misreporting remains common. This study provides deeper insight into the motivations leading to this behaviour in adolescents, suggesting that further understanding and attention to this aspect of adherence may lead to improvements not only in glycaemic control and safety, but also to the psychological wellbeing of those with T1DM.

A novel tool to predict youth who will show recommended usage of diabetes technologies

BACKGROUND AND OBJECTIVE

Controversy exists regarding which individuals will benefit most from commencement of diabetes technologies such as continuous subcutaneous insulin infusion (CSII) or continuous glucose monitoring systems (CGMS), such as 'real-time' sensor-augmented pumping (SAP). Because higher usage correlates with haemoglobin A1c (HbA1c) achieved, we aimed to predict future usage of technologies using a questionnaire-based tool.

SUBJECTS

The tool was distributed to two groups of youth with type 1 diabetes; group A (n = 50; mean age 12 ± 2.5 yr) which subsequently commenced 'real-time' CGMS and group B (n = 47; mean age 13 ± 3 yr) which commenced CSII utilisation.

METHODS

For the CGMS group, recommended usage was ≥5 days (70%) per week [≥70% = high usage (HU); <70% = low usage (LU)], assessed at 3 months. In the CSII group, HU was quantified as entering ≥5 blood sugars per day to the pump and LU as <5 blood sugars per day, at 6 months from initiation. Binary logistic regression with forward stepwise conditional was used to utilise tool scales and calculate an applied formula.

RESULTS

Of the CGMS group, using gender, baseline HbA1c, and two subscales of the tool generated a formula which predicted both high and low usage with 92% accuracy. Twelve (24%) showed HU vs. 38 who exhibited LU at 3 months. Of the CSII group, 32 (68%) exhibited HU vs. 15 who exhibited LU at 6 months. Four tool items plus gender predicted HU/LU with 95% accuracy.

CONCLUSIONS

This pilot study resulted in successful prediction of individuals who will and those who will not go on to show recommended usage of CSII and CGMS.

Treatment intensification without improved HbA1c levels in children and adolescents with Type 1 diabetes mellitus

AIMS

To examine trends in diabetes treatment in Danish children and adolescents with Type 1 diabetes mellitus, comparing treatment intensity with metabolic outcomes in the population, and to describe the challenges of population-based registries in a clinical setting with rapidly changing treatment methods.

METHODS

This observational study is based on the Danish national population registry of childhood diabetes, which includes 99% of children diagnosed with Type 1 diabetes before the age of 15 years. We included 4527 people diagnosed between 2000 and 2012. Self-monitored blood glucose measurements, insulin injections/boluses, treatment method and metabolic control quantifications were analysed and adjusted for the effects of gender and ethnicity, the combined effect of age, visit year and duration, and for the random effects of individual and hospital settings.

RESULTS

Treatment was intensified via an increasing number of self-monitored blood glucose measurements and injections/boluses. More than six injections/boluses and an increased number of self-monitored blood glucose measurements were significantly associated with lower metabolic control. No reduction, however, in the overall mean HbA1c concentration was observed between 2005 [66 mmol/mol (8.2%)] and 2012 [65 mmol/mol (8.1%)]. Changed registration practices in 2009 introduced artificial jumps in data.

CONCLUSIONS

Intensifying treatment alone does not lead to improved metabolic control in the overall population despite the appearance of lower HbA1c in individuals with a greater number of self-monitored blood glucose measurements and injections/boluses. The contradictory results reflect difficulties in using observational studies to predict results of intervention in the individual. Data collected from population-based registries need to be adjusted continuously to reflect changes in care.

Impact of insulin pump therapy on long-term glycemic control in a pediatric Spanish cohort

AIMS

To evaluate the efficacy and safety of Continuous Subcutaneous Insulin Infusion (CSII) in a pediatric cohort and to determine if the ISPAD/IDF/ADA criteria for good metabolic control are achieved during long periods of time.

METHODS

Retrospective longitudinal study including ninety patients [10.5 (6.5-13.9) years of age, 58% males]. Age at debut, type 1 diabetes mellitus duration, pubertal stage, HbA1c, insulin dose, mean number of glycemic controls, number of basal rates, % basal/total insulin, severe hypoglycemia and diabetic ketoacidosis events were analyzed. Subgroup analysis based on age and pubertal stage was performed.

RESULTS

HbA1c decreased from 6.9% [52 mmol/mol] to 6.7% [50 mmol/mol] after one year of CSII. Afterwards, it remained less than 7% during the follow-up period (median 3.5 ± 1.8 years (range 1-8). Prior to CSII, 76% of the subjects met ISPAD/ADA criteria. One year after initiating CSII, 96% of children had HbA1c<7.5%. Improvement in glycohemoglobin levels was most prominent in those patients with the highest HbA1c initial levels. Total insulin dose decreased from 0.89 to 0.73 UI/kg/day (p<0.001). Proportion of basal/total insulin changed significantly (47 to 42% (p<0.05)). Number of fractions of the basal rate increased from 5.6 ± 1.8 at one year of CSII to 6.7 ± 2.1 five years later. Incidence of severe hypoglycemic events decreased from 19 to 6.9 episodes/100 patient-year. Only 2 episodes of diabetic ketoacidosis occurred.

CONCLUSIONS

CSII allows reaching ISPAD/IDF/ADA goals safely during an extended follow-up period in a diabetic pediatric cohort.

A pilot study of factors associated with glycaemic control in adults with Type 1 diabetes mellitus on insulin pump therapy

AIMS

To identify the knowledge and management factors associated with glycaemic control among adults with Type 1 diabetes mellitus treated with insulin pump therapy.

METHODS

A cross-sectional study of adults with Type 1 diabetes mellitus on insulin pump therapy for at least 12 months (n = 50, 18-70 years old) was undertaken between December 2013 and May 2014. A new questionnaire was developed to evaluate participants' knowledge and management related to insulin pump therapy, and were correlated with insulin pump data, HbA1c and frequency of hypoglycaemia.

RESULTS

Participants who changed their insulin pump settings when indicated had significantly better glycaemic control than those who did not (P = 0.04). Multivariate logistic regression analysis found that better overall insulin pump therapy management was a significant predictor of better glycaemic control (odds ratio 4.45, 95% confidence interval 1.61-12.3; P = 0.004) after adjusting for potential confounders including age, gender, duration of diabetes and insulin pump therapy. However, overall insulin pump therapy knowledge was not a significant predictor of glycaemic control (P = 0.058). There was no significant association between frequency of hypoglycaemia and insulin pump therapy knowledge or management.

CONCLUSIONS

We identified some key knowledge and management factors associated with glycaemic control in adults with Type 1 diabetes mellitus on insulin pump therapy using a newly designed questionnaire. The pilot study assessed the clinical utility of this evaluation tool, which may facilitate provision of targeted education to insulin pump therapy users to achieve optimal glycaemic control.

Comparison between adherence assessments and blood glucose monitoring measures to predict glycemic control in adults with type 1 diabetes: a cross-sectional study

BACKGROUND

Adherence to treatment has been defined as the degree to which a patient's behavior corresponds to medical or health advice; however, the most appropriate method to evaluate adherence to diabetes care has yet to be identified. We conducted analyses to compare adherence assessments and blood glucose monitoring measures with regard to their ability to predict glycemic control in adults with type 1 diabetes.

METHODS

We analyzed four instruments to evaluate adherence: Self-Care Inventory-Revised, a self-administered survey; Diabetes Self-Monitoring Profile (DSMP), administered by trained researchers; a categorical (yes/no/sometimes) adherence self-evaluation; and a continuous (0-100) adherence self-evaluation. Blood glucose monitoring frequency was evaluated by self-report, diary, and meter download.

RESULTS

Participants (n = 82) were aged 39.0 ± 13.1 years with a mean diabetes duration of 21.2 ± 11.1 years; 27 % monitored blood glucose >4 times/day. The DSMP score was the strongest predictor of glycemic control (r = -0.32, P = 0.004) among adherence assessments, while blood glucose monitoring frequency assessed by meter download was the strongest predictor among blood glucose monitoring measures (r = -40, P < 0.001). All the self-report assessments had a significant but weak correlation with glycemic control (r ≤ 0.28, P ≤ 0.02). The final adjusted model identified the assessment of blood glucose monitoring frequency by meter download as the most robust predictor of HbA1c (estimate effect size = -0.58, P = 0.003).

CONCLUSIONS

In efforts to evaluate adherence, blood glucose monitoring frequency assessed by meter download has the strongest relationship with glycemic control in adults with type 1 diabetes.

The influence of age, gender, insulin dose, BMI, and blood pressure on metabolic control in young patients with type 1 diabetes

OBJECTIVE

To explore the relationship between certain clinical variables and metabolic HbA1c at diagnosis correlated to HbA1c at follow-up (p < 0.001). There was a clear gender difference regarding HbA1c. Girls had higher values both at diagnosis and at follow-up (p < 0.001). Girls also had lower BMI and pH at diagnosis than boys (p < 0.001). In contrast, girls with the highest body mass index (BMI) at follow-up had higher mean HbA1c at follow-up in 2010 (p < 0.001). Having a mother and/or a father with high BMI implied higher HbA1c at diagnosis (p < 0.003).

CONCLUSIONS

HbA1c at diagnosis seems to predict metabolic control years later. There is a gender difference at diagnosis as female patients have higher HbA1c than males at diagnosis as well as at follow up. As metabolic control is very much correlated to complications there is a need to early identify patients at risk of poor metabolic control. Even though we do not know whether a high HbA1c level is mainly due to severity of the disease or to behavioral patterns, new ways to treat and support these children, especially girls, are needed.

Adherence in adolescents with Type 1 diabetes: strategies and considerations for assessment in research and practice

Suboptimal adherence remains a significant concern for adolescents with Type 1 diabetes, the treatment regimen for which is complex and includes numerous behaviors. Accurate assessment of adherence is critical for effective healthcare and to measure trial outcomes. Without a valid biomarker of adherence, assessment strategies must rely on measuring management behaviors. This paper provides an overview of approaches to measure adherence, with an emphasis on contemporary, validated measures that are appropriate for current diabetes care. Objective measures include electronic data from diabetes management devices. Subjective measures include self/parent-report questionnaires, structured interviews and diaries/logbooks. Practical strategies for selecting measurement approaches for clinical and research purposes are reviewed, and implications of adherence assessment for clinical care delivery and adherence-promotion are discussed.