Continuous glucose monitoring in youth with type 1 diabetes: 12-month follow-up of the Juvenile Diabetes Research Foundation continuous glucose monitoring randomized trial

Impact of continuous glucose monitoring on everyday life of young children with type 1 diabetes and their parents: An evaluation of 114 families

INTRODUCTION

The prevalence of type 1 diabetes is increasing worldwide. The advent of new monitoring devices has enabled tighter glycemic control.

AIM

To study the impact of glucose monitoring devices on the everyday life of young children with type 1 diabetes (T1D) and their parents.

METHODS

A questionnaire was addressed to parents of children with T1D under the age of 6 years with an insulin pump treated in one of the hospitals of the ADIM network in France between January and July 2020.

RESULTS

Among the 114 families included in the study, 53% of parents (26/49) woke up every night to monitor blood glucose levels when their child had flash glucose monitoring (FGM), compared with 23% (13/56) of those whose child had continuous glucose monitoring (CGM). Overall, 81% of parents (86/108) found that glucose monitoring improved their own sleep and parents whose child had CGM were significantly more likely to report improved sleep (86% vs 73%, p = 0.006). Forty-nine percent of parents (55/113) declared that they (in 87% of cases, the mother only) had reduced their working hours or stopped working following their child's T1D diagnosis. Maternal unemployment was significantly associated with the presence of siblings (p = 0.001) but not with glycemic control (p = 0,87). Ninety-eight percent of parents (105/107) think that glucose monitoring improves school integration.

CONCLUSION

In these families of children with T1D, new diabetes technologies reduced the burden of care but sleep disruption remained common. Social needs evaluation, particularly of mothers, is important at initial diagnosis of T1D in children.

Roadmap to Continuous Glucose Monitoring Adoption and Improved Outcomes in Endocrinology: The 4T (Teamwork, Targets, Technology, and Tight Control) Program

Glucose monitoring is essential for the management of type 1 diabetes and has evolved from urine glucose monitoring in the early 1900s to home blood glucose monitoring in the 1980s to continuous glucose monitoring (CGM) today. Youth with type 1 diabetes struggle to meet A1C goals; however, CGM is associated with improved A1C in these youth and is recommended as a standard of care by diabetes professional organizations. Despite their utility, expanding uptake of CGM systems has been challenging, especially in minoritized communities. The 4T (Teamwork, Targets, Technology, and Tight Control) program was developed using a team-based approach to set consistent glycemic targets and equitably initiate CGM and remote patient monitoring in all youth with new-onset type 1 diabetes. In the pilot 4T study, youth in the 4T cohort had a 0.5% improvement in A1C 12 months after diabetes diagnosis compared with those in the historical cohort. The 4T program can serve as a roadmap for other multidisciplinary pediatric type 1 diabetes clinics to increase CGM adoption and improve glycemic outcomes.

Cystic Fibrosis-Related Diabetes Workshop: Research Priorities Spanning Disease Pathophysiology, Diagnosis, and Outcomes

Cystic fibrosis (CF) is a recessive disorder arising from mutations in the gene encoding the cystic fibrosis transmembrane conductance regulator (CFTR) protein. CFTR is expressed in numerous tissues, with high expression in the airways, small and large intestine, pancreatic and hepatobiliary ducts, and male reproductive tract. CFTR loss in these tissues disrupts regulation of salt, bicarbonate, and water balance across their epithelia, resulting in a systemic disorder with progressive organ dysfunction and damage. Pancreatic exocrine damage ultimately manifests as pancreatic exocrine insufficiency that begins as early as infancy. Pancreatic remodeling accompanies this early damage, during which abnormal glucose tolerance can be observed in toddlers. With increasing age, however, insulin secretion defects progress such that CF-related diabetes (CFRD) occurs in 20% of teens and up to half of adults with CF. The relevance of CFRD is highlighted by its association with increased morbidity, mortality, and patient burden. While clinical research on CFRD has greatly assisted in the care of individuals with CFRD, key knowledge gaps on CFRD pathogenesis remain. Furthermore, the wide use of CFTR modulators to restore CFTR activity is changing the CFRD clinical landscape and the field's understanding of CFRD pathogenesis. For these reasons, the National Institute of Diabetes and Digestive and Kidney Diseases and the Cystic Fibrosis Foundation sponsored a CFRD Scientific Workshop, 23-25 June 2021, to define knowledge gaps and needed research areas. This article describes the findings from this workshop and plots a path for CFRD research that is needed over the next decade.

Cystic Fibrosis-Related Diabetes Workshop: Research Priorities Spanning Disease Pathophysiology, Diagnosis, and Outcomes

Cystic fibrosis (CF) is a recessive disorder arising from mutations in the gene encoding the cystic fibrosis transmembrane conductance regulator (CFTR) protein. CFTR is expressed in numerous tissues, with high expression in the airways, small and large intestine, pancreatic and hepatobiliary ducts, and male reproductive tract. CFTR loss in these tissues disrupts regulation of salt, bicarbonate, and water balance across their epithelia, resulting in a systemic disorder with progressive organ dysfunction and damage. Pancreatic exocrine damage ultimately manifests as pancreatic exocrine insufficiency that begins as early as infancy. Pancreatic remodeling accompanies this early damage, during which abnormal glucose tolerance can be observed in toddlers. With increasing age, however, insulin secretion defects progress such that CF-related diabetes (CFRD) occurs in 20% of teens and up to half of adults with CF. The relevance of CFRD is highlighted by its association with increased morbidity, mortality, and patient burden. While clinical research on CFRD has greatly assisted in the care of individuals with CFRD, key knowledge gaps on CFRD pathogenesis remain. Furthermore, the wide use of CFTR modulators to restore CFTR activity is changing the CFRD clinical landscape and the field's understanding of CFRD pathogenesis. For these reasons, the National Institute of Diabetes and Digestive and Kidney Diseases and the Cystic Fibrosis Foundation sponsored a CFRD Scientific Workshop, 23-25 June 2021, to define knowledge gaps and needed research areas. This article describes the findings from this workshop and plots a path for CFRD research that is needed over the next decade.

Differences in positive expectancy of hybrid closed loop (HCL) insulin delivery systems do not explain racial differences in HCL use

Aims

Hybrid closed loop (HCL) insulin delivery systems improve glycemia and quality of life among youth with type 1 diabetes (T1D), however there are inequities in use. We aimed to evaluate whether differences in positive expectancy of HCL systems may explain differences in use.

Methods

Fifteen publicly-insured, non-Hispanic Black (NHB) youth with hemoglobin A1_C (HbA1c) ≥ 10% enrolled in a study exploring changes in glycemia and person reported outcomes (PRO) during 6 months of Tandem t:slim X2 insulin pump with Control-IQ technology. At baseline youth and parents completed PROs, including Insulin Delivery Systems: Perceptions, Ideas, Reflections and Expectations (INSPIRE) survey assessing positive expectancy of HCL use, and Problem Areas in Diabetes (PAID) survey assessing diabetes-related distress. Differences between this cohort and the Tandem Control-IQ pediatric pivotal trial (DCLP5) cohort were assessed.

Results

As compared to the DCLP5 cohort (0% NHB, 10% publicly-insured), baseline glycemic indicators were suboptimal (M_HbA1c 11.9 ± 1.4% vs 7.6 ± 0.9%, p < 0.0001; continuous glucose monitor (CGM) time-above-range > 180 mg/dL 82 ± 15% vs 45 ± 18%, p < 0.0001). INSPIRE scores in both cohorts were equally high among youth (80 ± 10 vs 77 ± 13, p = 0.41) and parents (88 ± 14 vs 85 ± 11, p = 0.37). PAID scores were higher among parents (68 ± 19 vs 43 ± 16, p < 0.0001), but not youth (43 ± 16 vs 35 ± 16, p = 0.09) in the historically marginalized cohort as compared to the DCLP5 cohort.

Conclusions

Despite differences in glycemic control and diabetes related burden, positive expectancy of HCL systems is comparable among historically marginalized youth with T1D and the predominantly non-Hispanic White, privately insured DCLP5 cohort. These findings suggest that differences in perceptions of HCL technology may not explain inequities in use.

Application of the FreeStyle®Libre Glucose Monitoring System in type 1 diabetes mellitus patients aged 1-4 years

BACKGROUND

To investigate the analytical accuracy, safety performance, and user satisfaction (guardians of study participants) of the FreeStyle®Libre Glucose Monitoring System in the treatment of type 1 diabetes mellitus (T1DM), in children aged <4 years.

METHODS

Sixteen hospitalized children with new onset T1DM, aged 4 months to 4 years, were enrolled in this study. Patients wore the sensor for 14 days; sensor scans were performed immediately and at 5, 10, and 15 min after capillary blood glucose (BG) measurements to evaluate the effectiveness of the device and the lag effect.

RESULTS

The consensus error grid showed that 96.40% of values fell within zone A (no clinical impact) and 3.60% within zone B (little/no clinical impact). Overall, the mean absolute relative difference (MARD) was 9.34%, and was higher in the capillary BG <4.0 mmol/L group (15.18%) than in the 4-10 mmol/L (9.63%) and >10 mmol/L (7.17%) groups. The MARD increased gradually with scanning time extension, indicating a short lag effect. Regression analysis showed that a higher BG level was associated with a greater difference in FreeStyle®Libre System measurements.

CONCLUSIONS

The use of the FreeStyle®Libre System in children aged 1-4 years is accurate and safe, and may be accurate down to 4 months, independent of patient characteristics.

Diabetes Technology Experiences Among Latinx and Non-Latinx Youth with Type 1 Diabetes

BACKGROUND

Diabetes technologies, such as insulin pumps and continuous glucose monitors (CGM), have been associated with improved glycemic control and increased quality of life for young people with type 1 diabetes (T1D); however, few young people use these devices, especially those from minority ethnic groups. Current literature predominantly focuses on white patients with private insurance and does not report experiences of diverse pediatric patients with limited resources.

METHODS

To explore potential differences between Latinx and non-Latinx patients, English- and Spanish-speaking young people with T1D (n = 173, ages 11-25 years) were surveyed to assess attitudes about and barriers to diabetes technologies using the Technology Use Attitudes and Barriers to Device Use questionnaires.

RESULTS

Both English- and Spanish-speaking participants who identified as Latinx were more likely to have public insurance (P = .0001). English-speaking Latinx participants reported higher Hemoglobin A1c values (P = .003), less CGM use (P = .002), and more negative attitudes about technology (generally, P = .003; and diabetes-specific, P < .001) than either non-Latinx or Spanish-speaking Latinx participants. Barriers were encountered with equivalent frequency across groups.

CONCLUSIONS

Latinx English-speaking participants had less positive attitudes toward general and diabetes technology than Latinx Spanish-speaking and non-Latinx English-speaking peers, and differences in CGM use were associated with socioeconomic status. Additional work is needed to design and deliver diabetes interventions that are of interest to and supportive of patients from diverse ethnic and language backgrounds.

Does introduction of continuous glucose monitoring at diagnosis of type 1 diabetes increase uptake in children and adolescents?

OBJECTIVE

To assess whether introduction of continuous glucose monitoring (CGM) at diagnosis of type 1 diabetes (T1D), leads to greater uptake and continuation at 12 and 24 months, in a population-based pediatric diabetes clinic.

RESEARCH DESIGN AND METHODS

All T1D children and adolescents diagnosed in the 12 months following full government subsidization of CGM were offered CGM from diagnosis at Women's and Children's Hospital, SA (Cohort 1). Uptake and continuation of CGM was compared to those diagnosed in the preceding year, who were started on CGM after diagnosis, but otherwise had identical diabetes management (Cohort 2). Demographic and clinical data were collected prospectively. The primary outcome variable was CGM wear >75% of the time at 12 and 24 months.

RESULTS

In Cohort 1, 84% were started on CGM at diagnosis. 88% had commenced CGM by 12 months and 90% by 24 months. In Cohort 2, CGM was started on average 10 months after diagnosis (range 1-25 months), with 81% started on CGM within 24 months of subsidization. At 24 months, 78% of Cohort 1 and 66% of Cohort 2 were wearing CGM >75% of the time (p = 0.26), higher than the WCH Clinic as a whole (58%). There was no difference in HbA1c between cohorts.

CONCLUSION

Starting CGM at diagnosis of T1D is feasible and well received by families, with high uptake across all ages. Although CGM continuation (wearing CGM >75% of the time) was slightly higher in Cohort 1 than Cohort 2, this did not reach statistical significance.

Cystic fibrosis-related diabetes: The patient perspective

Cystic fibrosis-related diabetes (CFRD) affects nearly 20% of adolescents and 40-50% of adults. However, the impact on patients and their families is poorly understood. Here, we examine how patients perceive CFRD and identify gaps in our understanding of the patient experience. Despite its relatively high prevalence, data suggest that many individuals are not aware of the possibility of developing CFRD or compare it to other types of diabetes. Annual oral glucose tolerance testing (OGTT) may serve as an opportunity to provide education and prepare individuals for the possibility of developing abnormalities in glucose tolerance. Many cite lack of awareness of CFRD as the most difficult part of the diagnosis. While factors such as older age and a strong support system promote acceptance, most individuals view the diagnosis negatively and struggle to balance the demands of diabetes with other obligations, including airway clearance, nebulizer therapies, supplementation nutrition, and administration of vitamins and medications. Relatively few people with CFRD monitor their blood glucoses consistently, which is attributed to time constraints or an attempt to avoid pain. In addition, many feel that they are not prone to hypoglycemia and are not concerned with long-term complications, anticipating that they will succumb to their pulmonary disease before these become problematic. The adolescent period presents unique challenges for adherence as children work to develop autonomy. Factors that promote CFRD adherence include incorporating management into daily CF routines and the support of knowledgeable providers to help develop an individualized approach to management. Diabetes technology has the potential to reduce treatment burden and improve glycemic control, but data in CFRD are limited, and additional study is needed. Given that CFRD is associated with a decline in health-related quality of life, it is critical that providers understand patients' perspectives and address gaps in understanding and barriers to management.

Perceptions of Diabetes Technology Use in Cystic Fibrosis-Related Diabetes Management

Background: Diabetes technologies are associated with improvements in glycemic control and health-related quality of life among people with type 1 diabetes (T1D). Use and perceptions of continuous glucose monitors (CGM) and insulin pumps within the cystic fibrosis (CF) community have not been well studied. Methods: A 30-item online survey addressing cystic fibrosis-related diabetes (CFRD) diagnosis, CGM and insulin pump use, and perceptions of diabetes technologies was sent to a CF community group, including people with CF (pwCF) and parents of children with CF (cwCF). Results: The response rate was 11% (n = 120; 83 pwCF, 35 cwCF). Sixty-one percent of pwCF and 34% of cwCF reported a diagnosis of CFRD. CGM use was reported by 75% (n = 47) of respondents with CFRD but was discontinued by 19% (n = 9), most commonly due to cost and increased worry about glycemia. Insulin pump therapy was reported by 29% (n = 18 of 62) of respondents with CFRD and was discontinued by 28% (n = 5), most commonly due to pain or skin irritation. Overall, 91% agreed or strongly agreed that CGM facilitated CFRD management. Eighty-one percent agreed with at least five of seven positive statements about CGM as compared with 22% for insulin pumps. Potential embarrassment over device wear, concerns about cost, and pain were commonly held negative perceptions of both technologies. Conclusions: As compared with T1D and despite perceived benefits, rates of sustained diabetes technology use are low in the CFRD community. Better insurance coverage to mitigate cost, better patient education, and confirmation that these technologies improve health and patient-reported outcomes may increase uptake.

Technological Ecological Momentary Assessment Tools to Study Type 1 Diabetes in Youth: Viewpoint of Methodologies

Type 1 diabetes (T1D) is one of the most common chronic childhood diseases, and its prevalence is rapidly increasing. The management of glucose in T1D is challenging, as youth must consider a myriad of factors when making diabetes care decisions. This task often leads to significant hyperglycemia, hypoglycemia, and glucose variability throughout the day, which have been associated with short- and long-term medical complications. At present, most of what is known about each of these complications and the health behaviors that may lead to them have been uncovered in the clinical setting or in laboratory-based research. However, the tools often used in these settings are limited in their ability to capture the dynamic behaviors, feelings, and physiological changes associated with T1D that fluctuate from moment to moment throughout the day. A better understanding of T1D in daily life could potentially aid in the development of interventions to improve diabetes care and mitigate the negative medical consequences associated with it. Therefore, there is a need to measure repeated, real-time, and real-world features of this disease in youth. This approach is known as ecological momentary assessment (EMA), and it has considerable advantages to in-lab research. Thus, this viewpoint aims to describe EMA tools that have been used to collect data in the daily lives of youth with T1D and discuss studies that explored the nuances of T1D in daily life using these methods. This viewpoint focuses on the following EMA methods: continuous glucose monitoring, actigraphy, ambulatory blood pressure monitoring, personal digital assistants, smartphones, and phone-based systems. The viewpoint also discusses the benefits of using EMA methods to collect important data that might not otherwise be collected in the laboratory and the limitations of each tool, future directions of the field, and possible clinical implications for their use.

Pediatric Medicaid Patients With Type 1 Diabetes Benefit From Continuous Glucose Monitor Technology

BACKGROUND

We determined the uptake rate of continuous glucose monitors (CGMs) and examined associations of clinical and demographic characteristics with CGM use among patients with type 1 diabetes covered by Colorado Medicaid during the first two years of CGM coverage with no out-of-pocket cost.

METHOD

We retrospectively reviewed data from 892 patients with type 1 diabetes insured by Colorado Medicaid (Colorado Health Program [CHP] and CHP+, Colorado Medicaid expansion). Demographics, insulin pump usage, CGM usage, and hemoglobin A1c (A1c) were extracted from the medical record. Data downloaded into CGM software at clinic appointments were reviewed to determine 30-day use prior to appointments. Subjects with some exposure to CGM were compared to subjects never exposed to CGM, and we examined the effect of CGM use on glycemic control.

RESULTS

Twenty percent of subjects had some exposure to CGM with a median of 22 [interquartile range 8, 29] days wear. Sixty one percent of CGM users had >85% sensor wear. Subjects using CGM were more likely to be younger (P < .001), have shorter diabetes duration (P < .001), and be non-Hispanic White (P < .001) than nonusers. After adjusting for age and diabetes duration, combined pump and CGM users had a lower A1c than those using neither technology (P = .006). Lower A1c was associated with greater CGM use (P = .002) and increased percent time in range (P < .001).

CONCLUSION

Pediatric Medicaid patients successfully utilized CGM. Expansion of Medicaid coverage for CGM may help improve glycemic control and lessen disparities in clinical outcomes within this population.

Evaluation of Hemoglobin A1c before and after initiation of continuous glucose monitoring in children with type 1 diabetes mellitus

OBJECTIVES

The development of continuous glucose monitoring (CGM) systems has allowed for identification of blood sugar variations and trends in real-time that is not feasible with conventional self-monitoring of blood glucose. However, there is inconsistent data to show that the use of CGM leads to better glycemic control as measured by Hemoglobin A1c (HbA1c) in pediatric patients with type 1 diabetes mellitus. Our study aimed to compare the average HbA1c level in the 1-2 years prior to starting a CGM to the average HbA1c level in the 1-2 years immediately following CGM initiation in a sample of 1-20 year olds with type 1 diabetes mellitus.

METHODS

Participants were 90 youth (ages 1-20) followed for type 1 diabetes care at our institution who used a CGM for at least a 6 month time period. We performed a retrospective chart review to obtain up to four HbA1c values pre and post-CGM initiation each. We evaluated pre- and post-CGM initiation changes in mean HbA1c via dependent samples t-tests using IBM SPSS 24.0.

RESULTS

The mean HbA1c was 8.7% pre-CGM and decreased to 8.27% 9-12 months after CGM initiation in the overall sample. A statistically significant decrease in HbA1c was seen in patients who used multiple daily injections (p=0.02), those with a pre-CGM HbA1c greater than 9% (p=0.01), and those with a diabetes duration of 5-10 years (p=0.02).

CONCLUSION

CGM use was associated with a decrease in HbA1c over time which was statistically significant in some subgroups.

Feasibility of the Web-Based Intervention Designed to Educate and Improve Adherence Through Learning to Use Continuous Glucose Monitor (IDEAL CGM) Training and Follow-Up Support Intervention: Randomized Controlled Pilot Study

Background

Proper training and follow-up for patients new to continuous glucose monitor (CGM) use are required to maintain adherence and achieve diabetes-related outcomes. However, CGM training is hampered by the lack of evidence-based standards and poor reimbursement. We hypothesized that web-based CGM training and education would be effective and could be provided with minimal burden to the health care team.

Objective

The aim of this study was to perform a pilot feasibility study testing a theory-driven, web-based intervention designed to provide extended training and follow-up support to adolescents and young adults newly implementing CGM and to describe CGM adherence, glycemic control, and CGM-specific psychosocial measures before and after the intervention.

Methods

The “Intervention Designed to Educate and improve Adherence through Learning to use CGM (IDEAL CGM)” web-based training intervention was based on supporting literature and theoretical concepts adapted from the health belief model and social cognitive theory. Patients new to CGM, who were aged 15-24 years with type 1 diabetes for more than 6 months were recruited from within a public university’s endocrinology clinic. Participants were randomized to enhanced standard care or enhanced standard care plus the IDEAL CGM intervention using a 1:3 randomization scheme. Hemoglobin A_1c levels and psychosocial measures were assessed at baseline and 3 months after start of the intervention.

Results

Ten eligible subjects were approached for recruitment and 8 were randomized. Within the IDEAL CGM group, 4 of the 6 participants received exposure to the web-based training. Half of the participants completed at least 5 of the 7 modules; however, dosage of the intervention and level of engagement varied widely among the participants. This study provided proof of concept for use of a web-based intervention to deliver follow-up CGM training and support. However, revisions to the intervention are needed in order to improve engagement and determine feasibility.

Conclusions

This pilot study underscores the importance of continued research efforts to optimize the use of web-based intervention tools for their potential to improve adherence and glycemic control and the psychosocial impact of the use of diabetes technologies without adding significant burden to the health care team. Enhancements should be made to the intervention to increase engagement, maximize responsiveness, and ensure attainment of the skills necessary to achieve consistent use and improvements in glycemic control prior to the design of a larger well-powered clinical trial to establish feasibility.

Trial Registration

ClinicalTrials.gov NCT03367351, https://clinicaltrials.gov/ct2/show/NCT03367351.

Evaluation of Patient Willingness to Adopt Remote Digital Monitoring for Diabetes Management

Importance

Patients will decide whether to adopt remote digital monitoring (RDM) for diabetes by weighing its health benefits against the inconvenience it may cause.

Objective

To identify the minimum effectiveness patients report they require to adopt 36 different RDM scenarios.

Design, Setting, and Participants

This survey study was conducted among adults with type 1 or type 2 diabetes living in 30 countries from February to July 2019.

Exposures

Survey participants assessed 3 randomly selected scenarios from a total of 36. Scenarios described different combinations of digital monitoring tools (glucose, physical activity, food monitoring), duration and feedback loops (feedback in consultation vs real-time telefeedback by a health care professional or by artificial intelligence), and data handling modalities (by a public vs private company), reflecting different degrees of RDM intrusiveness in patients' personal lives.

Main Outcomes and Measures

Participants assessed the minimum effectiveness for 2 diabetes-related outcomes (reducing hypoglycemic episodes and preventing ophthalmologic complications) for which they would adopt each RDM (from much less effective to much more effective than their current monitoring).

Results

Of 1577 individuals who consented to participate, 1010 (64%; 572 [57%] women, median [interquartile range] age, 51 [37-63] years, 524 [52%] with type 1 diabetes) assessed at least 1 vignette. Overall, 2860 vignette assessments were collected. In 1025 vignette assessments (36%), participants would adopt RDM only if it was much more effective at reducing hypoglycemic episodes compared with their current monitoring; in 1835 assessments (65%), participants would adopt RDM if was just as or somewhat more effective. The main factors associated with required effectiveness were food monitoring (β = 0.32; SE, 0.12; P = .009), real-time telefeedback by a health care professional (β = 0.49; SE, 0.15; P = .001), and perceived intrusiveness (β = 0.36; SE, 0.06; P < .001). Minimum required effectiveness varied among participants; 34 of 36 RDM scenarios (94%) were simultaneously required to be just as or less effective by at least 25% of participants and much more effective by at least 25% of participants. Results were similar for participant assessments of scenarios regarding the prevention of ophthalmologic complications.

Conclusions and Relevance

The findings of this study suggest that patients require greater health benefits to adopt more intrusive RDM modalities, food monitoring, and real-time feedback by a health care professional. Patient monitoring devices should be designed to be minimally intrusive. The variability in patients' requirements points to a need for shared decision-making.

Intermittently Scanned and Continuous Glucose Monitor Systems: A Systematic Review on Psychological Outcomes in Pediatric Patients

Aim: To explore the impact of real-time continuous glucose monitoring (rtCGMs) or intermittently scanned/viewed CGM (isCGM) on psychological outcomes in children and caregivers, and to grade the level of evidence. Method: Systematic review of the literature from PubMed, Embase, Cochrane Library, Web of Science, CINAHL, Nursing reference center, Up to date, Google Scholar, and PsycINFO databases. The studies selected used validated questionnaires for investigating the psychological outcomes. We applied GRADE (Grading of Recommendations Assessment, Development and Evaluation) to rank the quality of a body of evidence. Results: A total of 192 studies were identified in the initial search and after the process of evaluation 25 studies were selected as appropriate to be included in this systematic review. We found in moderate quality studies that isCGM in adolescents can improve diabetes related distress, family conflicts, fear of hypoglycemia, and quality of life, while depression, anxiety, and quality of sleep have not yet been evaluated by validated questionnaires. In moderate-high quality studies, rtCGM technology does not impact on diabetes burden, diabetes specific family conflict, and depressive symptoms. The effect on fear of hypoglycemia, sleep quality, and anxiety is still debated and RCT studies powered to find significant results in psychological outcomes are lacking. RtCGM increases satisfaction and quality of life in parents and patients wearing rtCGM. Conclusion: these data present an interesting point to consider when families are deciding whether or not to start CGM use, choosing between rtCGM to reach a tighter metabolic control, or isCGM which allows greater benefits on psychological outcomes.

7. Diabetes Technology: Standards of Medical Care in Diabetes-2021

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the 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 (https://doi.org/10.2337/dc21-SPPC), 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 (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Cutaneous adverse events in a randomized controlled trial of flash glucose monitoring among youth with type 1 diabetes mellitus

BACKGROUND

The literature regarding flash glucose monitoring (FGM)-associated cutaneous adverse events (AE) is limited.

OBJECTIVES

This study among youth participating in a 6 month randomized controlled trial aimed to compare cutaneous AE between FGM and self-monitored blood glucose (SMBG) use and evaluate premature FGM sensor loss.

METHODS

Patients aged 13 to 20 years with type 1 diabetes were randomized to intervention (FGM and usual care) or control (SMBG and usual care). Participants self-reported cutaneous AEs electronically every 14 days. Reports were analyzed to determine frequency, type, and severity of cutaneous AEs, and evaluate premature sensor loss.

RESULTS

Sixty-four participants were recruited; 33 randomized to FGM and 31 to control. In total, 80 cutaneous AEs were reported (40 in each group); however, the proportion of participants experiencing cutaneous AEs was greater in the FGM group compared to control (58% and 23% respectively, P = .004). FGM participants most frequently reported erythema (50% of AEs), while controls most commonly reported skin hardening (60% of AEs). For FGM users, 80.0% of cutaneous AEs were mild, 17.5% moderate, and 2.5% severe. Among controls, 82.5% of cutaneous AEs were mild and 17.5% moderate. One participant ceased using FGM due to recurring cutaneous AEs. Additionally, over 6 months, 82% of FGM participants experienced at least one premature sensor loss, largely unrelated to a cutaneous AE.

CONCLUSIONS

Cutaneous FGM-associated AEs are common, and mostly rated as mild. However, the majority of users continued FGM despite cutaneous AEs. Awareness of cutaneous complications and mitigation measures may reduce cutaneous AEs and improve the overall experience of FGM.

Intermittently scanned continuous glucose monitoring is associated with high satisfaction but increased HbA1c and weight in well-controlled youth with type 1 diabetes

OBJECTIVE

We undertook a 24-month prospective observational single-center real-world trial to study impact of access to intermittently scanned continuous glucose monitoring (isCGM) on quality of life (QOL) and glycemic control of youth with type 1 diabetes (T1D).

METHODS

Between September 2016 and November 2017, 138 children and adolescents with T1D were recruited. Demographic, metabolic, and QOL data were collected during 24 months of routine follow-up. Primary endpoint was the evolution of QOL, with secondary outcomes change in HbA1c, occurrence of acute diabetes complications, and school absenteeism.

RESULTS

Ninety-two percent of participants found isCGM more user-friendly than capillary finger-stick tests and had high treatment satisfaction, without change in diabetes-specific QOL. HbA1c significantly increased from 7.2% (7.0-7.3) (55 mmol/mol [53-56]) at baseline to 7.6% (7.4-7.8) (60 mmol/mol [57-62]) at 12 months (P < .0001) and was unchanged up to 24 months. Overall increase was mainly driven by children with baseline HbA1c <7.0% (<53 mmol/mol). Additionally, BMI adjusted for age was higher at study end. In year before isCGM, 228 days per 100 patient-years of school absenteeism were reported, which dramatically decreased to 13 days per 100 patient-years (P = .016) after 24 months. Parents of children also reported less work absenteeism (P = .011).

CONCLUSION

The use of isCGM by T1D pediatrics is associated with high treatment satisfaction and fewer days of school absence. However, increased HbA1c and weight may reflect a looser lifestyle, with less attention to diet and more avoidance of hypoglycemia. Intensive education specifically focusing on these points may mitigate these issues.

Has subsidized continuous glucose monitoring improved outcomes in pediatric diabetes?

INTRODUCTION

In 2017, the Australian Federal Government fully subsidized continuous glucose monitoring (CGM) devices for patients under 21 years of age with T1D with the aim of reducing rates of severe hypoglycaemia (SH) and improving metabolic control. The aim of this study was to reports on metabolic outcomes in youth from a single tertiary centre.

METHODS

The study design was observational. Data were obtained on youth who commenced CGM between May 2017 and December 2019.

RESULTS

Three hundred and forty one youth who commenced CGM and had clinical outcome data for a minimum of 4 months. 301, 261, 216, 172, and 125 had outcome data out to 8, 12, 16, 20, and 24 months, respectively. Cessation occurred between 27.9% and 32.8% of patients 12 to 24 months after CGM commencement. HbA1c did not change in patients who continued to use CGM. In the 12 months prior to starting CGM the rate of severe hypoglycaemia events were 5.0 per 100 patient years. The rates of severe hypoglycaemia in those continuing to use CGM at 4, 8, 12, 16, 20, and 24 months, were 5.2, 5.1, 1.6, 6.1, 2.4, and 0 per 100 patient years, respectively.

DISCUSSION

Our experience of patients either ceasing or underusing CGM is less than reported in other cohorts but is nonetheless still high. There may have been a reduction in rates of severe hypoglycaemia over the 24 months follow up period; however, the absolute numbers of events were so low as to preclude meaningful statistical analysis.

The 'flash' adhesive study: a randomized crossover trial using an additional adhesive patch to prolong freestyle libre sensor life among youth with type 1 diabetes mellitus

AIMS

Although strategies to prevent premature sensor loss for flash glucose monitoring (FGM) systems may have substantial benefit, limited data are available. This study among youth with high-risk type 1 diabetes evaluated whether an additional adhesive patch over FGM sensors would reduce premature sensor loss frequency and not cause additional cutaneous adverse events (AEs).

METHODS

This is a six-month, open-label, randomized crossover trial. Participants were recruited at completion of prior 'Managing Diabetes in a Flash' randomized controlled trial and allocated to three months of Freestyle Libre FGM sensors with either standard adhesive (control) or additional adhesive patches (RockaDex, New Zealand) (intervention), before crossing over to the opposite study arm. Participants self-reported patch use or non-use, premature sensor loss and cutaneous AEs fortnightly via an electronic questionnaire.

RESULTS

Thirty-four participants were enrolled: mean age (± SD) 17.0 (± 2.2) years; mean HbA1c (± SD) 89 (± 16) mmol/mol (10.3% ± 1.4%). The response rate of questionnaires was 77% (314/408). Premature sensor loss was reported in 18% (58/314) of questionnaires: 20% (32/162) from intervention and 17% (26/152) from control (p = 0.56). Thirty-eight percent (118/314) of questionnaires were non-compliant to protocol allocation. However, per-protocol analysis showed similar findings. No significant difference in AEs was reported between compliant adhesive patch use and non-use (6% [5/78] and 3% [3/118], respectively, p = 0.27).

CONCLUSIONS

The adhesive patch investigated in this study does not appear to prevent premature FGM sensor loss. However, the low risk of AEs and low cost of an adhesive patch suggest an individualized approach to their use may still be warranted. Further research is needed to explore alternative strategies to prevent sensor loss.

Use of Factory-Calibrated Real-time Continuous Glucose Monitoring Improves Time in Target and HbA1c in a Multiethnic Cohort of Adolescents and Young Adults With Type 1 Diabetes: The MILLENNIALS Study

OBJECTIVE

International type 1 diabetes registries have shown that HbA_1c levels are highest in young people with type 1 diabetes; however, improving their glycemic control remains a challenge. We propose that use of the factory-calibrated Dexcom G6 CGM system would improve glycemic control in this cohort.

RESEARCH DESIGN AND METHODS

We conducted a randomized crossover trial in young people with type 1 diabetes (16-24 years old) comparing the Dexcom G6 CGM system and self-monitoring of blood glucose (SMBG). Participants were assigned to the interventions in random order during two 8-week study periods. During SMBG, blinded continuous glucose monitoring (CGM) was worn by each participant for 10 days at the start, week 4, and week 7 of the control period. HbA_1c measurements were drawn after enrollment and before and after each treatment period. The primary outcome was time in range 70-180 mg/dL.

RESULTS

Time in range was significantly higher during CGM compared with control (35.7 ± 13.5% vs. 24.6 ± 9.3%; mean difference 11.1% [95% CI 7.0-15.2]; P < 0.001). CGM use reduced mean sensor glucose (219.7 ± 37.6 mg/dL vs. 251.9 ± 36.3 mg/dL; mean difference -32.2 mg/dL [95% CI -44.5 to -20.0]; P < 0.001) and time above range (61.7 ± 15.1% vs. 73.6 ± 10.4%; mean difference 11.9% [95% CI -16.4 to -7.4]; P < 0.001). HbA_1c level was reduced by 0.76% (95% CI -1.1 to -0.4) (-8.5 mmol/mol [95% CI -12.4 to -4.6]; P < 0.001). Times spent below range (<70 mg/dL and <54 mg/dL) were low and comparable during both study periods. Sensor wear was 84% during the CGM period.

CONCLUSIONS

CGM use in young people with type 1 diabetes improves time in target and HbA_1c levels compared with SMBG.

Improving pediatric endocrinology trainees' knowledge about insulin pumps and continuous glucose monitors with online spaced education: Technology Knowledge Optimization in T1D (TeKnO T1D)

OBJECTIVE

We explored the impact of TeKnO T1D, an online, case-based, spaced education curriculum about insulin pump and continuous glucose monitor (CGM) use in pediatric type 1 diabetes management.

METHODS

Pediatric endocrinology fellows (n = 64) were randomized to receive an educational curriculum focused on either insulin pumps or CGMs. Fellows received interactive questions twice weekly via email or mobile app. Median time to completion was 76.5 days. The primary outcome was change in knowledge as measured by performance on multiple-choice questions (MCQ) from the pre-test to the post-test.

RESULTS

Forty-eight of 64 (75%) learners completed the curriculum and assessments. The pump group improved from 35.0 ± 15% on the pre-test MCQs to 61.1 ± 17% on the post-test, a 12.2 absolute percentage point greater improvement on pump-specific items than the CGM group (P = .03). The CGM group improved from 30.3 ± 15% on the pre-test MCQs to 61.4 ± 21% on the post-test, a 28.7 absolute percentage point greater improvement on CGM-specific items than the pump group (P < .001). Both groups were more likely to report an appropriate level of understanding of their respective technologies after completing the corresponding curriculum. In thematic analysis of qualitative data, fellows indicated that knowledge gains led to improved patient care. There was universal agreement about enjoyment and effectiveness of the curricula.

CONCLUSIONS

TeKnO T1D proved to be an engaging, effective way to improve endocrinology fellows' knowledge and confidence about insulin pumps and CGM use in the management of pediatric type 1 diabetes.

Achieving Nonenzymatic Blood Glucose Sensing by Uprooting Saturation

The saturation of nonenzymatic blood glucose sensors at lower than normal blood glucose levels has blocked their practical applications. The mechanistic understanding of the saturation, however, has long been under debate. Employing cyclic voltammetry, amperometry, and FTIR with various electrolytes of varying concentrations, we were able to uproot the saturation cause. It was found to be related to the hydroxide ion concentration, which must be 11 times greater than that of the glucose concentration, contrary to the prior understanding. Together with the satisfactory sensitivity at high pH, nonenzymatic blood glucose sensing has finally been achieved, eliminating the usual problem of electrochemical current saturation as well as the need for enzyme found in the present technology.

Overweight and obese children with optimal control in the T1D Exchange Registry: How are they different from lean children with optimal control?

AIMS

Increased adiposity is a risk factor for suboptimal diabetes control and cardiovascular disease (CVD) complications. Our goal was to identify modifiable behavioral characteristics of overweight and obese pediatric patients with type 1 diabetes mellitus (T1DM) who achieve optimal glycemic control and to evaluate their CVD risk compared to lean patients. Our hypothesis was that optimally controlled obese and overweight participants require more total daily insulin and are at higher CVD risk compared to optimally controlled lean participants.

METHODS

We analyzed a cohort of 9263 participants with T1DM aged <21 years in the T1D Exchange Registry. Optimal diabetes control was defined as HbA1c ≤ 7.5% (58 mmol/mol). We compared factors that influence glycemic control in lean, overweight and obese participants with optimal vs. suboptimal control, using logistic regression.

RESULTS

Age, race, overweight status, continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring (CGM) use were important variables influencing glycemic control. In the optimally controlled cohort, 27% of participants were overweight or obese versus 30% in the suboptimally controlled cohort (P < 0.001). Overweight and obese participants with optimal control were not significantly different from lean participants in terms of CSII use, total daily insulin dosage per kg of bodyweight, glucose checks per day, boluses with bedtime snack, use of CGM, but had higher LDL cholesterol and triglycerides, and lower HDL cholesterol (P < 0.05).

CONCLUSIONS

There were no differences in modifiable behavioral characteristics between the obese, overweight and lean optimally controlled participants. However, predictors of cardiovascular disease were higher in the overweight and obese group.

Continuous Glucose Monitoring in Bariatric Patients Undergoing Laparoscopic Sleeve Gastrectomy and Laparoscopic Roux-En-Y Gastric Bypass

BACKGROUND

Few investigations have been conducted that compared blood glucose in patients with diabetes mellitus (DM2) and morbid obesity who had undergone laparoscopic sleeve gastrectomy (LSG) or gastric bypass (LRYGB). We aimed to compare the effects of these procedures using continuous glucose monitoring (CGM).

METHODS

We prospectively studied patients that had qualified for LSG or LRYGB. The inclusion criteria were DM2 of ≤ 5 years, for which patients were taking oral anti-diabetic drugs, or no glucose metabolism disorder; and morbid obesity. CGM was performed between admission and the 10th postoperative day.

RESULTS

We studied 16 patients with DM2 and 16 without. Eighteen patients underwent LSG and 14 underwent LRYGB. The median hemoglobin A1c was 5.5% (5.4-5.9%) in DM2 patients, which did not differ from control (p = 0.460). Preoperative mean daily glucose concentration was similar between DM2 and control patients (p = 0.622). For patients with DM2, LRYGB was associated with more frequent low glucose status, and these episodes lasted longer than in DM2 patients that underwent LSG (p = 0.035 and 0.049, respectively). DM2 patients that underwent LRYGB demonstrated lower glucose concentrations from third postoperative day than those that underwent LSG. Patients without DM2 did not demonstrate differences in daily mean glucose concentrations, or in incidence nor duration of hypoglycemia throughout the observation period.

CONCLUSION

A significantly larger reduction in interstitial glucose concentration is present from third day in patients with DM2 who undergo LRYGB vs. LSG, accompanied by a lower incidence and shorter duration of low glucose episodes.

7. Diabetes Technology: Standards of Medical Care in Diabetes-2020

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the 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 (https://doi.org/10.2337/dc20-SPPC), 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 (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Improvement in Psychosocial Outcomes in Children with Type 1 Diabetes and Their Parents Following Subsidy for Continuous Glucose Monitoring

Background: In April 2017, the Australian Government announced the full subsidy of continuous glucose monitors (CGM) to children and young people <21 years with type 1 diabetes (T1D). This study aimed to evaluate the effect of CGM on psychosocial outcomes in a T1D pediatric population-based sample. Methods: Children with T1D, commencing CGM between June 2017 and January 2018, and their parents were recruited in a prospective cohort study in a tertiary pediatric hospital in Western Australia. Parents and children older than 12 years self-completed questionnaires at onset of CGM and 2 months later, on fear of hypoglycemia (FOH) and diabetes treatment satisfaction (DTS). Parents provided measures of sleep quality. Children completed the Gold hypoglycemia awareness score. Hemoglobin A1c (HbA1c) values were compared at baseline (BL) and follow-up (FU). Results: Sixty parents and 38 children provided measures at BL and FU. Parental total FOH decreased (mean score BL vs. FU; 50.0 vs. 44.3, P = 0.004) with reduction in the Worry subscore (28.2 vs. 24.2, P = 0.004). Furthermore, parental and child DTS increased. Parental sleep quality improved (P < 0.001) and overnight finger prick testing decreased (P < 0.001). Impaired hypoglycemic awareness decreased in children (26.3% vs. 10.5%, P = 0.031). HbA1c reduced from 8.4% (68 mmol/mol) to 8.1% (65 mmol/mol) (P = 0.036). Conclusions: Introduction of subsidized CGM showed early improvement in psychosocial and glycemic outcomes in patients and their families in Western Australia. Ongoing evaluation is essential to assess whether equitable access to CGM will translate to sustained benefits for Australian T1D pediatric patients.

Human Factors Associated with Continuous Glucose Monitor Use in Patients with Diabetes: A Systematic Review

Consistent continuous glucose monitor (CGM) use is associated with substantial improvements in glycemic control, yet the uptake and continued use of these technologies remains low. This systematic review aims to identify and summarize the state of science on human factors and their association with CGM use to inform training methods and best practices that support adherence to CGM use and automated insulin delivery systems. A literature search was conducted in PubMed, CINAHL, The Cochrane Library, and PsychInfo databases using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify studies that reported psychological human factors related to CGM or sensor-augmented pump use in patients with type 1 diabetes. In total, 389 records were identified through our database search and 26 studies published between 2010 and 2017 were included. Articles underwent quality appraisal using the Effective Public Health Practice Project Quality Assessment Tool and were categorized according to study outcomes. Identified human factors with a potential association with CGM use were treatment satisfaction, quality of life, emotional distress, and self-efficacy. Eight patient-reported barriers to CGM use were identified as a subcomponent of satisfaction. To date, studies of human factors associated with CGM use generally lack standardized measures and sufficient methodological rigor necessary to establish causation. A more robust understanding of how identified human factors influence CGM use is necessary. Future studies should test interventions that target human factors to improve consistency of use and establish best practices for enhancing patients' experience and acceptance of these technologies, especially within adolescents and young adults.

The value of Continuous Glucose Monitoring and Self-Monitoring of Blood Glucose in patients with Gestational Diabetes Mellitus during Ramadan fasting

INTRODUCTION

In order to achieve the recommended glycemic control, women with Gestational Diabetes Mellitus (GDM) are instructed to self-monitor blood glucose (SMBG) regularly. The purpose of this study was to evaluate glucose readings provided by Continuous Glucose Monitoring (CGM) and SMBG in GDM patients during Ramadan fasting.

METHODS

This is a prospective observational study that recruited GDM patients treated with diet ± metformin were enrolled. They agreed to wear the iPro®2 ProfessionalCGM device and to do SMBG by glucose reading meters, during fasting and after meals. We evaluated the rates of hypoglycemia and hyperglycemia in each approach. The frequency and timing of SMBG was investigated.

RESULTS

Twenty-five patients were recruited. A total of 36,628 readings by CGM device and 408 readings using glucose meters and were captured. Average glucose level was 103 ± 8 mg/dl (5.7 ± 0.4 mmol/l) and 113 ± 14 mg/d (6.28 ± 0.8 mmol/L) on CGM and glucose meters respectively. The rate of hyperglycemia was 5.65% and 14.2% and hypoglycemia was 4.35% and 1.5% using CGM and glucose meters respectively. While all hypoglycemic episodes occurred between 16:00-19:00 in both approaches, only 38 readings (9%) of SMBG readings were done in that time frame.

CONCLUSION

Although the frequency of SMBG using glucose meters for women with GDM and fasting Ramadan was acceptable, the timing was not. CGM detected more hypoglycemia and less hyperglycemia than SMBG. Relying on Intermittent SMBG in the management of GDM patients during Ramadan fasting might be misleading.

Is there an optimal strategy for real-time continuous glucose monitoring in pediatrics? A 12-month French multi-center, prospective, controlled randomized trial (Start-In!)

AIM

To compare the efficacy of three strategies for real-time continuous glucose monitoring (RT-CGM) over 12 months in children and adolescents with type 1 diabetes.

METHODS

A French multicenter trial (NCT00949221) with a randomized, controlled, prospective, open, and parallel-group design was conducted. After 3 months of RT-CGM, patients were allocated to one of three groups: return to self-monitoring of blood glucose, continuous CGM (80% of the time), or discontinuous CGM (40% of the time). The primary outcome was hemoglobin A1c (HbA1c) levels from 3 to 12 months. The secondary outcomes were acute metabolic events, hypoglycemia, satisfaction with CGM and cost.

RESULTS

We included 151 subjects, aged 2 to 17 years, with a mean HbA1c level of 8.5% (SD0.7; 69 mmol/mol). The longitudinal change in HbA1c levels was similar in all three groups, at 3, 6, 9 and 12 months. The medical secondary endpoints did not differ between groups. The rate of severe hypoglycemia was significantly lower than that for the pretreatment year for the entire study population. Subjects reported consistent use and good tolerance of the device, regardless of age or insulin treatment. The use of full-time RT-CGM for 3 months costs the national medical insurance system €2629 per patient.

CONCLUSION

None of the three long-term RT-CGM strategies evaluated in pediatric type 1 diabetes was superior to the others in terms of HbA1c levels. CGM-use for 3 months decreased rates of severe hypoglycemia. Our results confirm the feasibility of long-term RT-CGM-use and the need to improve educational support for patients and caregivers.

Clinical efficacy of Professional Continuous Glucose Monitoring in improving glycemic control among children with Type 1 Diabetes Mellitus: An Open-label Randomized Control Trial

Frequent self-monitoring of blood glucose (SMBG) is the only accurate method available for insulin dose titration in patients with T1DM. Professional continuous glucose monitoring (p-CGM) is blinded recording of glucose trends over 5–7 days and helps physicians to guide insulin titration to patient. This study was planned to assess efficacy of insulin dose adjustments, based on p-CGM plus SMBG in improving glycemic control compared to SMBG alone. We did an open-label, parallel design, randomized control trial among children (2–10 years) having T1DM for at least 6 months. Subjects in the intervention group were placed on p-CGM (iPRO 2™ Professional CGM, Medtronic, USA) for 3–5 days along with regular SMBG. Data from p-CGM was analyzed by physician and used to guide insulin titration along with SMBG over following 3 months. Control group had only SMBG records for titrating insulin doses. Primary outcome was change in HbA1c 3 months after intervention. A total of 68 eligible children were randomized, 34 each to either arms. Thirty children in intervention group and 33 in control group completed the study and were analyzed. It was found that there was more decreased unit change in HbA1c, percentage of low sugar records and total insulin requirement per day, after 3 months follow-up, in intervention group. However, difference was not significant except for total insulin Units/kg/day (p = 0.014). In sub-group analysis of children with baseline HbA1c >7.5%, there was a significant mean fall of HbA1c by 1.27% (p = 0.045). There were no major adverse events associated with p-CGM. We conclude that addition of p-CGM along with SMBG may help in adjusting insulin dose more effectively especially in children with higher baseline HbA1c.

Continuous Glucose Monitoring: A Brief Review for Primary Care Practitioners

Glycated hemoglobin A1c (HbA1c) is routinely used as a marker of average glycemic control, but it fails to provide data on hypoglycemia and glycemic variability, both of which are associated with adverse clinical outcomes. Self-monitoring of blood glucose (SMBG), particularly in insulin-treated patients, is a cornerstone in the management of patients with diabetes. SMBG helps with treatment decisions that aim to reduce high glucose levels while avoiding hypoglycemia and limiting glucose variability. However, repeated SMBG can be inconvenient to patients and difficult to maintain in the long term. By contrast, continuous glucose monitoring (CGM) provides a convenient, comprehensive assessment of blood glucose levels, allowing the identification of high and low glucose levels, in addition to evaluating glycemic variability. CGM using newer detection and visualization systems can overcome many of the limitations of an HbA1c-based approach while addressing the inconvenience and fragmented glucose data associated with SMBG. When used together with HbA1c monitoring, CGM provides complementary information on glucose levels, thus facilitating the optimization of diabetes therapy while reducing the fear and risk of hypoglycemia. Here we review the capabilities and benefits of CGM, including cost-effectiveness data, and discuss the potential limitations of this glucose-monitoring strategy for the management of patients with diabetes. FUNDING: Sanofi US, Inc.

Pediatric Endocrinology Trainees' Education and Knowledge About Insulin Pumps and Continuous Glucose Monitors

BACKGROUND

Recent data demonstrating a lack of improvement in average hemoglobin A1c levels despite the increased use of insulin pumps and continuous glucose monitors (CGMs) suggest that patients are not using these technologies optimally. Suboptimal provider understanding of these devices may be a contributing factor.

METHODS

We sought to assess fellows' knowledge, attitudes, and practices regarding insulin pumps and CGMs using a mixed-methods survey. We polled 42 pediatric endocrinology fellows and 69 attending physicians in pediatric endocrinology using items on a five-point Likert scale.

RESULTS

Perceived fellow knowledge of insulin pumps and CGMs was only 3.6 ± 1.0 and 3.6 ± 0.9, respectively. Despite consensus about the need for pediatric endocrinologists to understand these technologies, only 14.7% of fellows reported the presence of a formal curriculum about these technologies at their institutions. Potential gaps identified in fellows' knowledge include general use and troubleshooting, advanced insulin pump features, infusion sets and dermatological complications, systematic approach to data, interpretation and application of CGM data, and keeping pace with technological advances.

CONCLUSIONS

Our data suggest suboptimal fellow knowledge and understanding of insulin pumps and CGMs in pediatric type 1 diabetes management, which is likely attributable to inadequate education in fellowship training programs. The development of formal educational curricula targeting areas of weakness identified in this survey may improve clinician knowledge of these technologies and ultimately impact patient education and care.

Improving patient self-care using diabetes technologies

Diabetes technologies are an unstoppable phenomenon. They offer opportunities to improve patient self-care through empowerment. However, they can be a challenge for both patients and clinicians. Thus, the use of technology may empower or burden. To understand and benefit from the use of diabetes technologies, one must understand the currently unmet needs in diabetes management. These unmet needs call for perspectives beyond glycated hemoglobin and an evaluation of technology solutions. Optimal use of these technologies is necessary to obtain benefits and achieve cost-effectiveness; this process depends on diabetes education and training. This review evaluates clinician and patient perspectives regarding diabetes technologies, followed by an evaluation of technology solutions. Diabetes technology solutions are evaluated according to available results about their effectiveness and their potential to empower people living with diabetes.

Non-invasive blood glucose measurement of 95% certainty by pressure regulated Mid-IR

To fight against diabetes mellitus, from which more than 400 million people suffer in the world, the patients have to puncture their fingers 4-5 times a day for the blood glucose level checks when using a glucometer, causing invasive pain and the risk of infection. Therefore, non-invasive method has been urged for blood glucose monitoring, among which the mid-infrared spectroscopy (Mid-IR) response of interstitial fluid was found to be promising. However, despite the prolonged effort, the accuracy still falls below the FDA's requirement. To break this barrier which lasted for almost three decades, we discovered the finger contact pressure playing a critical role during the measurement, where the Mid-IR reading could be affected significantly by a small change of the finger posture. In addition, the Mid-IR absorption level was also found to be highly associated with individual, revealing the necessity of adjusting the calibration correlation for each patient. By imposing a certain contact pressure monitored by a pressure transducer, we were able to achieve over 95% certainty from the Mid-IR measurement of glucose concentration and 100% comparability to the "true" glucose concentration for the first time, which was mainly attributed to the morphological change of finger tissue under pressure. The previous works resulted in only about 70% accuracy on average, barely hitting 80 + %, whereas ours reaches 95%, finally exceeding the requirement of FDA.

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.

Outcomes of using flash glucose monitoring technology by children and young people with type 1 diabetes in a single arm study

BACKGROUND AND OBJECTIVE

Outcomes of using flash glucose monitoring have been reported in adults. This trial evaluated use in children and teenagers with type 1 diabetes.

METHODS

Prospective, single arm, non-inferiority multicenter study to demonstrate equivalence of time in range (TIR [70-180 mg/dL]) by comparing 14-day masked sensor wear (baseline) with self-monitored blood glucose (SMBG) testing to the final 14-days of 8-week open-label system use for diabetes self-management including insulin dosing.

RESULTS

A total of 76 children and teenagers (46.1% male; age 10.3 ± 4.0 years, type 1 diabetes duration 5.4 ± 3.7 years; mean ± SD) from 10 sites participated. TIR improved significantly by 0.9 ± 2.8 h/d (P = 0.005) vs SMBG baseline. Time in hyperglycemia (>180 mg/dL) reduced by -1.2 ± 3.3 h/d (P = 0.004). HbA1c reduced by -0.4% (-4.4 mmol/mol), from 7.9 ± 1.0% (62.9 ± 11.2 mmol/mol) baseline to 7.5 ± 0.9% (58.5 ± 9.8 mmol/mol) study end (P < 0.0001) with reductions across all age-subgroups (4-6, 7-12 and 13-17 years). Time in hypoglycemia (<70 mg/dL) was unaffected. Throughout the treatment phase system utilization was 91% ± 9; sensor scanning was 12.9 ± 5.7/d with SMBG dropping to 1.6 ± 1.9 from 7.7 ± 2.5/d. Diabetes Treatment Satisfaction Questionnaire "Total Treatment Satisfaction" score improved for parents (P < 0.0001) and teenagers (P < 0.0001). No adverse events (n = 121) were associated with sensor accuracy, 42 participants experienced sensor insertion signs and symptoms. Three participants experienced three mild device-related (sensor wear) symptoms, resolving quickly (without treatment [n = 2], non-prescription antihistamines [n = 1]).

CONCLUSIONS

Children with diabetes improved glycemic control safely and effectively with short-term flash glucose monitoring compared to use of SMBG in a single arm study.

Biopsychosocial Factors Associated With Satisfaction and Sustained Use of Artificial Pancreas Technology and Its Components: a Call to the Technology Field

PURPOSE OF REVIEW

Summarize biopsychosocial factors associated with using continuous glucose monitors (CGMs), insulin pumps, and artificial pancreas (AP) systems and provide a "call to the field" about their importance to technology uptake and maintained use.

RECENT FINDINGS

Insulin pumps and CGMs are becoming standard of care for individuals with type 1 diabetes (T1D). AP systems combining a CGM, insulin pump, and automated dosing algorithm are available for commercial use. Despite improved glycemic control with AP system use, numerous barriers exist which may limit their benefit. Studies on components of AP systems (pumps, CGMs) are limited and demonstrate mixed results of their impact on fear of hypoglycemia, adherence, quality of life, depression and anxiety, and diabetes distress. Studies examining biopsychological factors associated specifically with sustained use of AP systems are also sparse. Biological, psychological and social impacts of AP systems have been understudied and the information they provide has not been capitalized upon.

Accuracy of a Fourth-Generation Continuous Glucose Monitoring System in Children and Adolescents with Type 1 Diabetes

BACKGROUND

This study evaluated the safety and performance of the Guardian™ continuous glucose monitoring (CGM) system in children and adolescents with type 1 diabetes (T1D).

MATERIALS AND METHODS

Subjects 2-18 years of age (mean ± standard deviation [SD] 13.1 ± 3.9 years) with T1D and duration of diagnosis ≥1 year were enrolled at 11 sites in the United States and wore two Guardian Sensor 3 sensors in the abdomen and/or buttock. Sensors were connected to a transmitter paired with either a Guardian Connect system (i.e., mobile device with software application allowing display of sensor glucose [SG] values) or a Guardian Link 3 transmitter used as a Glucose Sensor Recorder (GSR). There were 145 participants who underwent a 6-h in-clinic frequent sample testing (FST) on day 1 (n = 54), day 3 (n = 48), or day 7 (n = 43) postsensor insertion. During FST, SG values were compared with a Yellow Springs Instrument (YSI) plasma reference every 5-15 min (n = 124, 7-18 years of age; n = 2, 2-6 years of age), or to a self-monitoring of blood glucose (SMBG) reference every 5-30 min (n = 19, 2-6 years of age).

RESULTS

The overall mean absolute relative difference (ARD ± SD) between SG and reference values (YSI or SMBG) when calibrating approximately every 12 h, was 10.9% ± 10.7% (3102 paired points) for sensors communicating with the Guardian Connect system and 11.1% ± 10.6% (2624 paired points) for sensors connected to the GSR. The overall percentage of SG values within ±20% of reference values >80 mg/dL or within 20 mg/dL of reference values ≤80 mg/dL was 87.8% for the Guardian Connect system and 86.7% for the GSR, respectively. There was one device-related adverse event of contact dermatitis, but no serious device-related adverse events.

CONCLUSIONS

The Guardian CGM system demonstrated good accuracy in children and adolescents. These findings support its use in sensor-integrated insulin pump platforms, as well as a standalone technology, for managing diabetes in pediatric populations.

Continuous Glucose Monitoring Associated With Less Diabetes-Specific Emotional Distress and Lower A1c Among Adolescents With Type 1 Diabetes

BACKGROUND

Psychosocial impact research of continuous glucose monitoring (CGM) and continuous subcutaneous insulin infusion (CSII) among adolescents with type 1 diabetes (T1D) is limited. The present study assesses associations between diabetes technology use on adolescent- and parent-perceived diabetes-specific distress and A1c.

METHOD

Adolescents with T1D and parents (N = 1040; primarily mothers) completed measures of diabetes distress. Adolescents were categorized by technology use: CGM Alone, CSII Alone, CGM+CSII, or No Technology. ANOVA, regression, and Cohen's d were used for group comparisons on measures of diabetes distress and A1c. Analyses also compared groups on clinical elevations of distress.

RESULTS

CGM use was associated with less adolescent distress compared to No Technology ( d = 0.59), CGM+CSII ( d = 0.26), and CSII Alone ( d = 0.29). Results were similar but with smaller effect size for parent-reported distress, although CGM+CSII showed equivocal association with parent distress compared to No Technology ( d = 0.18). CGM Alone was associated with lower A1c compared to No Technology ( d = 0.48), to CSII Alone ( d = 0.37), and was comparable to CGM+CSII ( d = 0.03). CGM+CSII conferred advantage over CSII Alone ( d = 0.34). Clinical elevation of distress was associated with not using any technology particularly for adolescents.

CONCLUSIONS

Technology use is associated with lower adolescent distress than lower parent distress. CGM Alone is associated with lower adolescent and parent distress than CSII or CGM+CSII. This appears to be clinically meaningful based on cut scores for measures. CGM is associated with lower A1c independent of being used alone or with CSII.

Baseline Psychosocial Characteristics Predict Frequency of Continuous Glucose Monitoring in Youth with Type 1 Diabetes

BACKGROUND

Consistent use of continuous glucose monitoring (CGM) has been associated with improved glycemic control in youth with type 1 diabetes (T1D). There are many barriers to device uptake and continued use. There is a need to understand patient-specific characteristics when considering CGM. We evaluated patterns of CGM use and associations between baseline psychosocial measures and frequency of CGM use over 1 year.

METHODS

Youth with T1D (n = 120), ages 8-18 years, completed questionnaires at CGM initiation and after 6 and 12 months assessing depressive symptoms, diabetes burden, and diabetes-specific and generic quality of life (QOL).

RESULTS

Youth (51% male and 95% white) had mean age 12.7 ± 2.7 years, diabetes duration 6.1 ± 3.6 years, and glycated hemoglobin (HbA_1c) 8.0 ± 0.8%. Over 1 year, 35% of youth used CGM 6 to 7 days per week, 45% used CGM 3-5 days per week, and 20% used CGM only 0-2 days per week. Youth who used CGM 3-7 days per week over 12 months had lower HbA_1c at months 9 and 12 than youth who used CGM 0-2 days per week (9 months: 7.9 ± 0.9% vs. 8.5 ± 1.1%, P = 0.006 and 12 months: 8.0 ± 0.9% vs. 8.5 ± 1.1%, P = 0.02). Those using CGM 0-2 days per week had greater endorsement of depressive symptoms and diabetes burden and reported lower QOL at baseline compared with those using CGM 3-7 days per week.

CONCLUSIONS

CGM use for 3 or more days per week over 12 months had a protective effect on HbA_1c. Providers should consider addressing psychosocial parameters when initiating CGM to maximize uptake and promote continued use in youth with T1D.

Best friend or spy: a qualitative meta-synthesis on the impact of continuous glucose monitoring on life with Type 1 diabetes

AIMS

This is a meta-synthesis of extant qualitative literature related to impact of continuous glucose monitoring (CGM). CGM has been available for a decade for the management of Type 1 diabetes and is the lynchpin of future artificial pancreas technologies. Clinical uptake of CGM is an important area of inquiry. The purpose of this meta-synthesis is to understand the impact of CGM on individuals with Type 1 diabetes and others (parents, significant others, providers) in order to design appropriate clinical interventions for adherence.

METHODS

Studies published in English between 2007 and 2017 were included, reflecting commercial CGM availability. PubMed, PsychINFO, CINALH, Web of Science and EMBASE databases were queried using search terms related to CGM, qualitative, experience and Type 1 diabetes. Included articles contained original qualitative or mixed-method research on CGM, sensor-augmented pump or closed-loop therapies. Articles underwent quality appraisal and thematic interpretive integration by a multidisciplinary team.

RESULTS

Nine articles (343 participants) met the inclusion criteria and were included in the synthesis. Six novel themes emerged: interacting with CGM, burden of living with CGM, feeling different from others, feeling empowered, interacting with glucose information and impact on relationships.

CONCLUSION

CGM affects physical, emotional and relational aspects of life. Clinicians can help minimize the burden of CGM with carefully delivered education and expectation-setting with individuals. Empowerment and relational partnerships in diabetes care can be explored to maximize satisfaction with CGM. Systematic interpretive synthesis of qualitative studies provides a comprehensive, contextual understanding of the impact of CGM on daily life and relationships.

Schooling diabetes: Use of continuous glucose monitoring and remote monitors in the home and school settings

BACKGROUND

Despite significant advances in type 1 diabetes (T1D) management, achieving targeted glycemic control in pediatric patients remains a struggle. Continuous glucose monitoring (CGM) with remote access holds the promise to address this challenge by allowing caregivers to monitor glucose, even when the child is not directly under their supervision.

OBJECTIVE

To explore real-time and remote CGM practices in homes and schools, including caregiver expectations regarding this technology.

SUBJECTS

Parents and daytime caregivers.

METHODS

Respondents answered an anonymous survey assessing characteristics of CGM use. Cross-sectional data were collected and analyzed using quantitative and qualitative methods.

RESULTS

Thirty-three parents and 17 daytime caregivers responded. Threshold alerts (alerts when patients reached certain pre-set high or low limits) were used most frequently, followed by rate of change alerts. Most parents and daytime caregivers responded to low- and high-threshold CGM alerts by confirming with a glucose meter prior to treatment; while about one-third endorsed treating lows without a confirmatory test. Most parents expected their child's daytime caregiver to respond to CGM alerts and daytime caregivers felt the parent's expectations of them were reasonable. All parents and most caregivers reported decreased overall worry/stress. Parents felt positive about CGM use and daytime caregivers felt comfortable with CGM.

CONCLUSION

The positive and collaborative management reported by parents and daytime caregivers sets the stage for CGM to play an important role in the management of children with T1D both in the home and in the school settings.