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

Evaluation of glycemia risk index and continuous glucose monitoring-derived metrics in type 1 diabetes: a real-world observational study

Objectives

The Glycemia Risk Index (GRI) quantifies the risk of glycemic events by considering both hypoglycemic and hyperglycemic episodes, offering a comprehensive evaluation of glycemia. While associations between GRI and various glycometric indicators have been established in clinical trials using continuous glucose monitoring (CGM), real-world assessments, particularly with intermittent scanning CGM (isCGM), are underexplored. This study examines these associations and their clinical implications in individuals with Type 1 Diabetes (T1D).

Methods

We conducted a retrospective study involving individuals with T1D undergoing intensive insulin therapy. All participants had used isCGM for at least three months. We collected clinical, metabolic, and glycemic data and calculated the GRI, with its components for hypoglycemia (CHypo) and hyperglycemia (CHyper). We then assessed the correlation between the GRI and traditional glycemic metrics in relation to the coefficient of variation (CV).

Results

The study included 194 patients (105 males, 89 females) with a median age of 21.5 years for adults and 16 years for adolescents. Of these, 62.4% were on multiple daily injections, and 37.6% used insulin pumps. GRI showed a significant negative correlation with Time in Range (%TIR70 - 180) (p  < 0.001) and a positive association with various glycemic measures such as glycemic variability (r = 0.33, p < 0.001). Individuals with lower glycemic variability (CV< 36%) had significantly higher %TIR70 - 180 (63% vs. 39%, p < 0.01) and lower GRI (40 vs. 45.8, p < 0.01), CHyper (20 vs. 24, p = 0.01), and CHypo (2.6 vs. 3.4, p < 0.01).

Conclusions

GRI correlates with key glycemic metrics, indicating its potential utility in comprehensive glycemia assessment. These findings highlight the importance of individualized treatment approaches and suggest GRI's clinical relevance in optimizing glycemic management strategies for individuals with T1D.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-025-01569-w.

Barriers to glucagon use in patients with type 1 diabetes

Glucagon use has been shown to be low in severe hypoglycemia events among adults with type 1 diabetes. In this study, we aimed to explore the barriers to using glucagon. We surveyed 576 adults with type 1 diabetes and demonstrated the barriers in using glucagon and speculated possible solutions.

The association of environmental mastery and diabetes distress among young adults with type 1 diabetes

AIMS

We determined whether a global measure of environmental mastery (EM) was associated with diabetes distress (DD) among young adults with type 1 diabetes (T1D).

METHODS

In 2017, an online survey was completed by 423 of 743 (57%) young adults (19-31 years) with T1D receiving care at a speciality clinic in New York City. Linear regression was used to examine the association between EM scores (7-item scale from Ryff's Scales of Psychological Well-Being) and DD scores (17-item Diabetes Distress Scale), adjusting for HbA1c levels and sociodemographic and clinical covariates.

RESULTS

Among the 416 participants with complete data on EM and DD, the mean (SD) age was 24.5 (3.2) years. Fifty-nine per cent were female and 70% were Non-Hispanic White. The mean HbA1c level was 64 (18) mmol/mol/8.0 (1.7) %, the mean EM score was 33.5 ± 8.7 and the mean DD score was 2.3 ± 1.0. For each 1 SD increase in EM score, there was a 0.51 SD decrease (95% confidence interval [CI]: 0.43, 0.59) in the covariate-adjusted DD score. This inverse association between EM and DD was of similar magnitude among those with HbA1c levels in the target range (<53 mmol/mol [<7.0%]) and those with HbA1c levels not in the target range.

CONCLUSIONS

Greater EM was associated with lower DD. Reducing DD in young adults with T1D may require a better understanding of the developmental processes that lead to a sense of global mastery.

Insulin Resistance in Type 1 Diabetes: Pathophysiological, Clinical, and Therapeutic Relevance

People with type 1 diabetes (T1D) are usually considered to exclusively exhibit β-cell failure, but they frequently also feature insulin resistance. This review discusses the mechanisms, clinical features, and therapeutic relevance of insulin resistance by focusing mainly on human studies using gold-standard techniques (euglycemic-hyperinsulinemic clamp). In T1D, tissue-specific insulin resistance can develop early and sustain throughout disease progression. The underlying pathophysiology is complex, involving both metabolic- and autoimmune-related factors operating synergistically. Insulin treatment may play an important pathogenic role in predisposing individuals with T1D to insulin resistance. However, the established lifestyle-related risk factors and peripheral insulin administration inducing glucolipotoxicity, hyperinsulinemia, hyperglucagonemia, inflammation, mitochondrial abnormalities, and oxidative stress cannot always fully explain insulin resistance in T1D, suggesting a phenotype distinct from type 2 diabetes. The mutual interaction between insulin resistance and impaired endothelial function further contributes to diabetes-related complications. Insulin resistance should therefore be considered a treatment target in T1D. Aside from lifestyle modifications, continuous subcutaneous insulin infusion can ameliorate insulin resistance and hyperinsulinemia, thereby improving glucose toxicity compared with multiple injection insulin treatment. Among other concepts, metformin, pioglitazone, incretin-based drugs such as GLP-1 receptor agonists, sodium-glucose cotransporter inhibitors, and pramlintide can improve insulin resistance, either directly or indirectly. However, considering the current issues of high cost, side effects, limited efficacy, and their off-label status, these agents in people with T1D are not widely used in routine clinical care at present.

Rationale and design of a randomised phase II multicentre crossover trial investigating a sodium-glucose co-transporter 2 inhibitor, dapagliflozin, combined with a novel continuous ketone monitor in adults with type 1 diabetes to reduce the risk of diabetic ketoacidosis: the PARTNER study

INTRODUCTION

Sodium-glucose co-transporter inhibitors have potential glycaemic and non-glycaemic benefits in people with type 1 diabetes (T1D). However, the increased risk of diabetic ketoacidosis (DKA) limits their widespread use. We hypothesise that dapagliflozin 10 mg daily, combined with the use of continuous ketone monitoring (CKM) and education strategies to mitigate progression to DKA, will demonstrate improved glycaemic control without increasing DKA events.

METHODS AND ANALYSIS

PARTNER is a multisite 6-month randomised crossover double-masked study involving Australian adults with T1D who have a Haemoglobin A1c (HbA1c) <85.8 mmol/mol (<10%), minimum total daily insulin dose ≥0.4 IU/kg, consume ≥100 g carbohydrates/day and have not had DKA in the last 3 months. All participants will undergo a 2-week run-in period wearing the Abbott FreeStyle Libre 2 Continuous Glucose Monitor (CGM) and Abbott CKM device. Following this, participants are randomised to receive dapagliflozin or placebo for 12 weeks, followed by crossover for a further 12 weeks separated by a 2-week washout period. The primary effectiveness outcome is the Abbott FreeStyle Libre 2 CGM time in range during the final 2 weeks of each stage. The primary safety outcome is the number of episodes of DKA requiring hospitalisation or emergency department presentation. 60 participants will be recruited across five sites.

ETHICS AND DISSEMINATION

The study has received ethical approval from the St Vincent's Hospital Melbourne Human Research Ethics Committee (HREC reference 302/23). The results will be published in peer-reviewed journals and presented at national and international diabetes conferences.

TRIAL REGISTRATION NUMBER

ACTRN12624000448549.

The experiences of high-risk young adults with type 1 diabetes transitioning to real-time continuous glucose monitoring - A thematic analysis

BACKGROUND

Real-time continuous glucose monitoring (rtCGM) is now the standard care for people with type 1 diabetes. However, whilst its impact on glycaemic outcomes is well-documented, its psychosocial effects, particularly in young adults experiencing extreme hyperglycaemia, remain poorly understood.

OBJECTIVES

We aimed to explore the psychosocial impact of rtCGM on young adults with extreme hyperglycaemia who thus far have not been studied extensively.

RESEARCH DESIGN AND METHODS

A qualitative study employing semi-structured interviews was undertaken. Young adults 18-25 years (HbA1c >75mmol/mol (9.0%)), naïve to rtCGM, were provided with rtCGM for 6-months. Interviews (centred on barriers to self-management and experience of rtCGM use) were conducted within 2-weeks of recruitment and at the end. An inductive, thematic analysis of interviews was undertaken.

RESULTS

Eight participants (median age (IQR) 23.0 (22.0-24.5) years, 100% non-white ethnicity) were recruited with median HbA1c 94 (88-107) mmol/mol [DCCT 10.8 (10.2-12.1)%.]. All participants used multiple daily insulin injections. Despite low rtCGM wear-time (32.2 (23.1-59.4)%), significant improvements were observed in time in range, but no change in HbA1c. Thematic analysis indicated that high levels of disease burden were reported, with rtCGM-related themes identified: 1) interaction with rtCGM data, 2) feelings of control and trust from using rtCGM, and 3) frustration of technology and alarms. Although participants reported that knowledge of glucose levels on their smartphone was convenient and led to 'greater control', this was countered by alarm-fatigue, technical difficulties and feeling overwhelmed. Three participants prematurely stopped using rtCGM.

CONCLUSIONS

Young adults with high-risk hyperglycaemia have complex relationships with rtCGM. rtCGM may have benefits in this high-risk group, but are likely to require additional support and must be determined on a case-by-case basis as associated effort may contribute to feelings of distress and/or burnout. Implementing structured educational, psychosocial, and technical support, alongside alternative care models such as more frequent check-ins, should be considered in order to enhance self-management practices with rtCGM and address technology-related challenges.

National trends in per-capita medical expenditures among U.S. adults with diabetes, 2000-2022

AIMS

To examine the national trend in per-capita medical expenditures among U.S. adults with diabetes from 2000 to 2022.

METHODS

We analyzed data from the Medical Expenditure Panel Survey in U.S. adults aged ≥18 years with self-reported diabetes. We calculated the expenditure in total and by component, including outpatient services, inpatient services, emergency room (ER) visits, prescription drugs, and other medical services. We used joinpoint regression to identify changes in trends.

RESULTS

Estimated total per-capita expenditure increased 66 %, from $9,700 (95 % CI $8,736-$10,663) in 2000 to $16,067 (95 % CI $15,049-$17,086) in 2022. Specifically, spending on prescription drugs, outpatient, ER, and other medical services increased by 144 %, 96 %, 122 %, and 135 %, respectively, while inpatient spending decreased by 28 %. Two significant upward trend periods (2000-2004 and 2011-2018) were identified for total expenditure. Spending trends by component varied, with an accelerated increase in prescription drug spending after 2012; by 2022, prescription drugs accounted for the largest share (39 %) of total expenditures.

CONCLUSIONS

The economic burden of diabetes on the national health care system has been increasing, with spending changes varying by medical service category. Interventions to prevent diabetes and its complications may help mitigate this growing economic burden.

A comparison of ultra-rapid and rapid insulin in automated insulin delivery for type 1 diabetes: A systematic review and meta-analysis of randomized controlled trials

AIMS

This study aimed to summarize and compare the evidence on the efficacy and safety of automated insulin delivery (AID) systems using ultra-rapid-acting insulin analogues (URAIs), such as fast-acting insulin aspart (FIASP) and ultra-rapid lispro (URLi) (referred to as AID-URAIs), versus those using rapid-acting insulin analogues (RAIs) (referred to as AID-RAIs) in patients with type 1 diabetes (T1D).

MATERIALS AND METHODS

We conducted a systematic review and meta-analysis of AID-URAI versus AID-RAI. We systematically searched PubMed, Scopus, ProQuest, Web of Science, Cochrane Library, Clinicaltrial.gov, and medRxiv for articles up to 30 October 2024. Percent time-in-range (TIR; 3.9-10 mmol/L), time-below-range (TBR; 3.9- and 3.0-mmol/L), and time-above-range (TAR; >10.0- and 13.9-mmol/L) were extracted. This study was registered in the PROSPERO (CRD42024602279).

RESULTS

Sixteen randomized controlled trials (664 participants) were included in this study. AID-URAI were associated with an increased percentage of TIR, but not clinically significant (pooled mean difference {MD} = 1.07% [95% confidence interval {CI}: 0.11 to 2.02]; I2 = 0%; p = 0.029; high certainty). The favourable effect was consistent in AID systems incorporating automated bolus correction, adults, study duration >4 weeks, and FIASP subgroups. AID-URAI has a 0.35% lower percentage of TBR (<3.9 mmol/L) compared with AID-RAI. There were no significant differences in the risk of diabetic ketoacidosis and severe hypoglycemia between the two groups.

CONCLUSIONS

AID-URAI slightly improves the percentage of TIR and has a good safety profile without increasing the risk of diabetic ketoacidosis and severe hypoglycemia.

Intervention to reduce barriers to type 1 diabetes self-management: Diabetes Journey study design and participant characteristics

Most adolescents with type 1 diabetes (T1D) encounter barriers to achieving optimal glycemia, including effective planning and monitoring their T1D and problem-solving, and following through with T1D treatment decisions. Thus, the overall aim of Diabetes Journey, a randomized controlled clinical trial, was to assess the feasibility, acceptability, and preliminary efficacy of a novel, amusement park-themed, web-based mobile health (mHealth) intervention tailored for adolescents who experienced barriers to T1D self-management. Secondary aims included examining post-intervention changes in T1D health-related quality of life, T1D self-management behaviors, and hemoglobin A1c (HbA1c). This article describes the study rationale, recruitment, design, and baseline characteristics of the adolescents (aged 12-17 years) who were randomized to one of two groups: Diabetes Journey or Enhanced Standard of Care. Diabetes Journey focused on reducing challenges related to stress, burnout, time pressure, and planning through the delivery of 5-8 intervention sessions using a problem-solving framework. Enhanced Standard of Care participants attended 4 education sessions focused on similar topics through the T1D Toolkit© website (educational content and brief videos about T1D). Adolescents (N = 195) were recruited with n = 162 randomized (Mage = 14.8 ± 1.6 years; 50 % female, 88 % White; HbA1c% = 8.2 ± 1.8; 86 % on insulin pumps). Diabetes Journey was impacted by COVID-19 and modifications to the study design were warranted. Future directions include examining the impact of Diabetes Journey on primary and secondary outcomes, while accounting for the impact of COVID-19.

Gaming the System: A Fun Continuous Glucose Monitor Interface Improves Glycemic Outcomes for Children

Achieving optimal glycemic control in children with type 1 diabetes (T1D) is challenging even when wearing a continuous glucose monitor (CGM). We measured the impact of eddii, a gamified real-time app connected to a CGM, on glycemic control. An open label, eight-week randomized controlled trial (RCT) compared glycemic control utilizing the gamified CGM app connected to Dexcom G6 with only Dexcom G6 usage. Children with T1D using Dexcom G6 were enrolled (N=92, ages 5-12 years). Time-in-range (TIR) data were collected four weeks prior to and during the study period. The gamified CGM app utilization effect was measured by difference-in-difference (D-I-D) models. The TIR and time-above-range (TAR) improved among users of the gamified CGM app; 5.38% higher and 5.80% lower than controls (P = .001 and P = .019, respectively).

Developing a multicomponent intervention to increase glucose time in range in adolescents and young adults with type 1 diabetes: An optimisation trial to screen continuous glucose monitoring, sleep extension, healthier snacking and values-guided self-management intervention components

AIM

The study aimed to identify active intervention components to improve glucose sensor time in range (TIR; 70-180 mg/dL [3.9-10.0 mmol/L]) by ≥5 % among adolescents and young adults (13 to 20 yrs) with type 1 diabetes and above recommended glycated haemoglobin (HbA1c ≥ 7.5 % [≥ 58 mmol/mol]), regardless of current insulin therapy.

METHODS

The 6-week optimisation trial used a 24 factorial experiment to estimate the main effects and interactions of the following candidate intervention components on TIR: real-time continuous glucose monitoring (CGM) technology, sleep extension, healthier snacking support, and values-guided self-management. Twenty-one participants, mean (SD) age 16.1 (2.4) years, were randomised to one of 16 experimental conditions.

RESULTS

The main effects, as measured by the mean difference (95 % CI) in TIR from baseline to 4 weeks, were: CGM, 3.3 (-8.8, 15.4) percentage points; sleep extension, -7.2 (-19.0, 4.6) percentage points; snacking support, 0.9 (-11.8, 13.5) percentage points; values-guided self-management, 6.1 (-7.5, 19.7) percentage points.

CONCLUSIONS

The values-guided self-management was the only 'active' component. Conclusions about the less impactful intervention components are limited due to disruptions in research activities from the COVID-19 pandemic. Future work will address other candidate intervention components.

Therapeutic Inertia Quantification in Diabetes Care: A Narrative Review and Synthesis

PURPOSE

Therapeutic inertia, which refers to the failure to adjust therapy despite suboptimal glycemic control, is a growing concern. This phenomenon is associated with significant adverse health consequences and reflects the gap between population health goals and patient outcomes. Current research lacks harmonized and effective ways to measure therapeutic inertia, posing significant challenges to addressing this issue in diabetes care. This review aimed to summarize the approaches used to quantify therapeutic inertia in diabetes care, with the goal of improving clinical management and patient outcomes.

METHODS

A narrative review was conducted to identify relevant articles through a search of MEDLINE (PubMed), Embase, and Web of Science databases from their inception until August 2024, employing search terms related to therapeutic inertia, quantification, and diabetes care. We included all articles that focused on quantifying therapeutic inertia in diabetes care. Quantification methods were summarized with respect to key aspects of formula, scoring, validation, advantages, and limitations.

FINDINGS

Four approaches for quantifying therapeutic inertia were identified from the retrieved articles. However, these methods have several limitations that have led to the development of a therapeutic inertia index. The primary goal of the index as a quality measure is to describe healthcare providers' practices and establish a connection between the implemented process measures and key glycemic outcomes. Three commonly used therapeutic inertia indices have been reported in the literature: the norm-based method, standard-based method (SBM), and American Diabetes Association method.

IMPLICATIONS

There is a need to standardize therapeutic inertia measurement approaches and develop comprehensive interventions to enhance the management of diabetes.

Once-Weekly Insulin Versus Once-Daily Insulin for Type 1 Diabetes Treatment: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

BACKGROUND

Type 1 diabetes mellitus (T1DM) represents a considerable global health burden, affecting approximately 5%-10% of individuals with diabetes. Once-weekly basal insulin could substantially reduce the number of injections for T1DM patients from 365 daily to 52 weekly doses annually. Therefore, this meta-analysis compares the safety and efficacy of once-weekly insulin formulations.

METHODS

The systematic review and meta-analysis included the relevant randomised controlled trials (RCTs) retrieved from PubMed, EMBASE, Web of Science, Cochrane, and SCOPUS databases until September 2024. The meta-analysis was performed using (RevMan 5.4.1). The study protocol was registered on PROSPERO (CRD42024603022).

RESULTS

Three RCTs comprising 1724 participants were included. Once-daily insulin significantly decreased glycated haemoglobin (HbA1c) compared to once-weekly insulin (estimated treatment difference: 0.09%, 95% CI [0.07, 0.11], p < 0.00001). Fasting blood glucose levels were comparable between the once-weekly and once-daily insulin groups (estimated treatment difference: 0.44 mg/dL, 95% CI [-0.64, 1.52], p = 0.42). Once-weekly insulin was associated with a significant increase in the incidence of injection site reactions (RR: 3.48 with 95% CI [1.30, 9.31], p = 0.01), serious adverse events (RR: 1.55 with 95% CI [1.09, 2.19], p = 0.01), and treatment-emergent adverse events (RR: 1.12 with 95% CI [1.02, 1.23], p = 0.02), while no significant difference was observed in hypersensitivity reactions (RR: 1.04 with 95% CI [0.78, 1.38], p = 0.79).

CONCLUSION

Once-daily insulin has demonstrated slightly superior HbA1c reduction, while once-weekly insulin offers potential advantages in patient adherence. However, these benefits must be weighed against an increased risk of injection site reactions and nocturnal hypoglycemia. Although once-weekly insulin is more convenient, treatment decisions should consider individual patient factors such as hypoglycemia risk and tolerance to injection reactions.

Islet Transplantation Versus Standard of Care for Type 1 Diabetes Complicated by Severe Hypoglycemia From the Collaborative Islet Transplant Registry and the T1D Exchange Registry

OBJECTIVE

Islet transplantation was recently approved by the U.S. Food and Drug Administration for adults with type 1 diabetes complicated by recurrent severe hypoglycemia events (SHEs). We sought to understand the long-term benefit for glycemic control and risk of immunosuppression to kidney function associated with islet transplantation compared with ongoing standard of care.

RESEARCH DESIGN AND METHODS

We performed a case-control analysis of prospectively collected data from patients in the Collaborative Islet Transplant Registry (CITR) with at least one SHE in the year (2000-2014) before transplantation (case subjects) and compared them with data from patients in the T1D Exchange (T1DX) Registry with at least one SHE in the year (2010-2012) before enrollment (control subjects), with both cohorts observed over 5 years. SHEs were restricted to those resulting in seizure or loss of consciousness.

RESULTS

Case subjects from CITR (n = 71) compared with control subjects from T1DX (n = 213) more often achieved the primary outcome of HbA1c <7.0% and absence of an SHE (71-80% vs. 21-33% over 5 years; P < 0.001) and the outcome of HbA1c ≤6.5% and absence of an SHE (60-75% vs. 10-20%; P < 0.001) while requiring significantly less insulin (majority in CITR were insulin independent). Kidney function, measured by estimated glomerular filtration rate, declined from baseline to a greater extent in CITR than in T1DX (-8.8 to -20 vs. -1.3 to -6.5 mL ⋅ min-1 ⋅ 1.73 m-2 over 5 years; P < 0.001).

CONCLUSIONS

Islet transplantation for adults with type 1 diabetes complicated by SHEs results in near-normal glycemic control in the absence of SHEs more often than observed with standard of care, but at the cost of greater reduction in kidney function.

Diabetes visits in paediatric versus adult clinics for young adults (YA) with T1D: Pre-pandemic and pandemic care

BACKGROUND

Young adults (YA) with type 1 diabetes mellitus (T1D) are at high risk of worsening glycated haemoglobin (HbA1c) with fewer follow-up visits. We examined the association of demographic and diabetes characteristics with care utilization, including in-person and telehealth visits, pre- (1 April 2019 to 15 March 2020) and during the COVID-19 pandemic (30 March 2020 to 15 March 2021) for YA (ages: 18-30) with T1D, comparing those seen in paediatric versus adult diabetes clinics at a single diabetes centre.

METHODS

Data were obtained from the electronic health record for YA with a pre-pandemic HbA1c. We performed descriptive statistics to describe the sample and paired t-tests to compare visits before and during the pandemic.

RESULTS

Data from 1762 YA (54% male; age 24.0 ± 3.6 (M ± SD) years; HbA1c 66 ± 18 mmol/mol (8.2 ± 1.6%) revealed that in the full sample, mean pre-pandemic visit frequency was 3.5 ± 3.4 and mean pandemic visit frequency was 3.1 ± 4.1 (p < 0.0001). Furthermore, the pandemic visit frequency declined in the adult clinic regardless of sex, pump therapy, CGM use, and pre-pandemic HbA1c, whereas in the paediatric clinic, visit frequency was only reduced for those with HbA1c <53 mmol/mol (<7%) but was otherwise maintained.

CONCLUSIONS

In this diabetes centre, the paediatric clinic maintained diabetes care delivery during the pandemic (30 March 2020 to 15 March 2021) to YA with glycaemic control above target, suggesting that preservation of remote care delivery should be considered in this high-risk group.

Social disadvantage and technology use among adults with type 1 diabetes in Quebec: A cross-sectional study using data from the Canadian T1D (BETTER) Registry

AIMS

We evaluated associations between social disadvantage and insulin pump and continuous glucose monitor (CGM) use among adults with type 1 diabetes (T1D) in Quebec, Canada, where public funding is available for CGM but not for insulin pumps.

MATERIALS AND METHODS

We conducted a cross-sectional analysis using self-reported survey data collected from April 2019 to October 2023. Primary exposures were social disadvantage indicators (Race, income, education, employment, insurance, immigration, rural/urban location). Primary outcomes were insulin pump and CGM use. Logistic regression was used to assess associations between social disadvantage indicators and the odds of insulin pump and CGM use.

RESULTS

Among 2380 adults with T1D, 37.4% used insulin pumps and 82.5% used CGM. Insulin pump use was lower among those with income <$80 000 (odds ratio [OR] 0.64 [95% confidence interval 0.50-0.82]), no post-secondary education (OR 0.62 [0.46-0.85]), non-White Race (OR 0.47 [0.30-0.73]) and public insurance (OR 0.47 [0.35-0.62]). CGM use was lower only among those with income <$80 000 (OR 0.61 [0.45-0.83]) and public insurance (OR 0.61 [0.45-0.83]). Odds of insulin pump and CGM use were successively lower with an increasing number of social disadvantage indicators. Insulin pump and CGM use were both associated with lower HbA1c but not severe hypoglycaemia or diabetes hospitalisation.

CONCLUSIONS

Social disadvantage is associated with lower uptake of insulin pumps and CGM among Quebec adults with T1D, though public funding partially mitigates disparities in CGM use. Given the benefits and increasing recommendations for automated insulin delivery, strategies to increase the uptake of diabetes technologies among socially disadvantaged individuals are required.

PLAIN LANGUAGE SUMMARY

Social disadvantage is linked to lower use of insulin pumps and CGM in adults with T1D in Quebec. Public funding narrows CGM disparities, but broader equity strategies are needed.

Exploring patterns in pediatric type 1 diabetes care and the impact of socioeconomic status

BACKGROUND

Managing pediatric type 1 diabetes is complex and requires substantial parental involvement. Adherence to clinical guidelines is often inconsistent, and lower parental socioeconomic status is associated with worse outcomes in affected children. However, few studies have examined these children's care pathways multidimensionally over time. This study aims to identify latent clusters in the care pathways of pediatric patients with type 1 diabetes mellitus, evaluate guideline adherence and disease management within these clusters, and assess the influence of socioeconomic status on cluster membership.

METHODS

We analyzed care pathways for pediatric patients with type 1 diabetes from 2017 to 2019 in the German health system, which provides universal coverage. Using state sequence analysis and clustering algorithms from the TraMineR R package, we identified patient clusters based on healthcare utilization patterns. To assess care quality within these clusters, we compared observed care patterns to clinical guideline recommendations. Our analysis was based on health insurance claims data from Techniker Krankenkasse, a statutory health insurer. From the dataset, which encompassed more than three million patients under the age of 25 years, we derived an age-homogeneous cohort of continuously insured children aged 11 to 14 years with type 1 diabetes in 2017 and extracted relevant healthcare events over a 3-year period.

RESULTS

Based on care patterns, we identified two clusters of children, which we designated as the "guideline-adherent" and "care-with-gaps" clusters. Roughly 25% of our cohort (n = 890) fell into the latter cluster, consistently receiving care that fell short of guideline recommendations. For example, these patients had less than half as many quarters with hemoglobin A1c measurement. Lower parental educational attainment and unemployment were predictors of this suboptimal care. We also found that the average number of hospitalizations per child was almost 40% higher in the cluster with less guideline-adherent care.

CONCLUSIONS

Despite universal health coverage and frequent contact with the outpatient healthcare system, a substantial proportion of pediatric type 1 diabetes patients in Germany experience suboptimal care, particularly in glycemic diagnostics and screening for complications, leading to worse health outcomes. Higher socioeconomic status is associated with care that more closely adheres to clinical guidelines.

Adolescent Girls With Type 1 Diabetes Develop Changes in Bone Prior to Evidence of Clinical Neuropathy

CONTEXT

Neuropathy and fracture are prevalent complications of type 1 diabetes (T1D). Although correlated in the clinical literature, it remains unknown whether neuropathy contributes to the initiation of bone loss at the earliest stages of disease.

METHODS

We performed a single-center, cross-sectional study to quantify parameters of nerve and bone health in adolescent girls with T1D (n = 21) and associated controls (n = 12). Groups were well matched for age, height, strength, and physical activity.

RESULTS

By high-resolution peripheral quantitative computed tomograpy, participants with T1D had lower trabecular bone volume fraction at the distal radius (-14.6%, P-adj = .095) and the tibia (-12.8%, P-adj = .017) and decreased trabecular thickness (-8.3% radius, P-adj = .007; -7.5% tibia, P-adj = .034) after adjustment for body size. In the tibia only, cortical bone mineral density was increased by 8.6% (P-adj = .024) and porosity was decreased by 52.9% with T1D (P-adj = .012). There were no significant differences in bone density by dual-energy x-ray absorptiometry. Participants with T1D also had lower circulating levels of osteocalcin (-30%, P = .057), and type I collagen cross-linked C-telopeptide (-36%, P = .035), suggesting low bone formation and turnover in T1D. Based on the Michigan Neuropathy Screening Instrument, 9.5% of those with T1D had clinical evidence of diabetic peripheral neuropathy. However, consideration of neuropathy status failed to explain the widespread T1D-associated changes in bone.

CONCLUSION

Our study defines early deficits in trabecular bone microarchitecture, decreased cortical porosity in the tibia, and suppression of biomarkers of bone turnover in adolescent girls with T1D, prior to the onset of symptomatic peripheral neuropathy. These findings inform our understanding of the rapid progression of skeletal disease in young girls with T1D and suggests that early detection and management strategies may help to prevent fracture and related comorbidities later in life.

Breath Acetone Correlates With Capillary β-hydroxybutyrate in Type 1 Diabetes

BACKGROUND

Breath acetone (BrACE) is an end product of ketone metabolism that is measurable by noninvasive breath ketone analyzers. We assessed the correlation between capillary blood β-hydroxybutyrate (BOHB) and BrACE in people with type 1 diabetes during 14 days of outpatient care with and without dapagliflozin treatment and during supervised insulin withdrawal studies with and without dapagliflozin.

METHODS

In this randomized crossover study, participants completed two 14-day outpatient periods with or without dapagliflozin 10 mg daily. Each 14-day unsupervised outpatient period was followed by a 1-day supervised insulin withdrawal study. Paired BOHB and BrACE measurements were obtained 3 times daily during outpatient periods, then hourly during supervised insulin withdrawal. The correlation between BrACE and BOHB was assessed by Spearman's ρ.

RESULTS

Twenty people with type 1 diabetes completed the study. During outpatient periods, BrACE and BOHB were moderately correlated (n = 1425 paired readings; ρ = .41; 95% CI = 0.36 to 0.45; P < .0001). However, BrACE and BOHB were strongly correlated during insulin withdrawal (n = 246 paired values, ρ = .81; 95% CI = 0.77 to 0.85). In ROC analysis, BrACE > 5 ppm demonstrated optimal sensitivity (93%) and specificity (87%) for detecting capillary BOHB ≥ 1.5 mmol/L. No serious adverse events occurred.

CONCLUSIONS

In adults with type 1 diabetes, measurement of breath acetone provides a noninvasive estimate of blood BOHB concentration. The correlation between BrACE and BOHB was suboptimal during unsupervised outpatient care, but was strong during supervised insulin withdrawal.

TRIAL REGISTRATION

clinicaltrials.gov (NCT05541484).

Closed-loop therapy: recent advancements and potential predictors of glycemic outcomes

INTRODUCTION

Hybrid closed-loop systems have become the standard of care for managing type 1 diabetes (T1D). Both clinical trials and real-world data have demonstrated that these systems improve glycemic control without increasing the risk of hypoglycemia, while also reducing the overall burden of T1D management. A systematic literature search was conducted using PubMed for studies including individuals with T1D that were published until the end of 2024.

AREAS COVERED

In this review, we summarize the safety and efficacy of currently available hybrid closed-loop systems, drawing from key clinical trials and real-world data analyses. We also highlight recent advancements in closed-loop systems, discuss their limitations and barriers to access, and explore future directions for automated insulin delivery. Finally, we explore potential predictors of outcomes for people with T1D to better understand why some individuals respond better to closed-loop systems than others.

EXPERT OPINION

Closed-loop systems are advancing rapidly, with a growing focus on enhancing automation through fully closed-loop systems to improve glycemic control and further reduce the burden of management. Identifying the predictors that influence how individuals respond to closed-loop therapy will enable these systems to be optimized. It is crucial to ensure widespread and equitable access to this advanced technology.

Seasonal, weekly, and individual variations in long-term use of wearable medical devices for diabetes management

Wearable medical-grade devices are transforming the standard of care for prevalent chronic conditions like diabetes. Yet, adoption and long-term use remain a challenge for many people. In this study, we investigate patterns of consistent versus disrupted use of continuous glucose monitors (CGMs) through analysis of more than 118,000 days of data, with over 22 million blood glucose samples, from 108 young adults with type 1 diabetes (average: 3 years of CGM data per person). In this population, we found more consistent CGM use at the start and end of the year (e.g., January, December), and more disrupted CGM use in the middle of the year/warmer months (i.e., May to July). We also found more consistent CGM use on weekdays (Monday to Thursday) and during waking hours (6AM - 6PM), but more disrupted CGM use on weekends (Friday to Sunday) and during evening/night hours (7PM - 5AM). Only 52.7% of participants (57 out of 108) had consistent and sustained CGM use over the years (i.e., over 70% daily wear time for more than 70% of their data duration). From semi-structured interviews, we unpack factors contributing to sustained CGM use (e.g., easier and better blood glucose management) and factors contributing to disrupted CGM use (e.g., changes in insurance coverage, issues with sensor adhesiveness/lifespan, and college/life transitions). We leverage insights from this study to elicit implications for next-generation technology and interventions that can circumvent seasonal and other factors that disrupt sustained use of wearable medical devices for the goal of improving health outcomes.

Development, validation, and item bias assessment of the Self-Care Inventory-Short-Form among racially and income-diverse adolescents living with type 1 diabetes and their caregivers

OBJECTIVE

Youth with type 1 diabetes and their families engage in complex health behaviors to help manage blood glucose levels and to reduce the risk of serious health complications. Given well-documented health disparities in pediatric diabetes, rapid and equitable assessment of diabetes self-care can help identify potential areas where support is needed. This purpose of this study was to (a) develop a short-form of the Self-Care Inventory-Revised (SCI-R) and (b) evaluate validity, reliability, and differential item functioning (DIF) across several socio-illness-demographic variables of the full and short-form SCI-R.

METHODS

Participants were 181 adolescent-caregiver dyads from the Predicting Resiliency in Youth with Type 1 Diabetes (PRYDE) study who completed a 15-item version of the SCI-R. Adolescents (age: M = 14.64, SD =1.70, range 12-18 years), identifying as female (n = 92), male (n = 92), Black/AA (57%), and/or White (43%), also completed diabetes-specific measures of stress and Health-related Quality of Life (T1D-HRQoL). Youths' most recent hemoglobin A1c (HbA1c) values were extracted from their medical records.

RESULTS

Initial items selected based on the six highest factor loadings of 15 were evaluated using DIF analyses. The final 6-item youth and caregiver SCI-SF6 totals correlated with HbA1c, stress, and T1D-HRQoL. They were invariant across participant dyads at the scalar level (root mean squared error of approximation =.077, 90% CI: .056-.098; comparative fit index =.971, standardized root mean square residual = .0490). DIF analyses failed to reject the null hypothesis for item bias factor loadings or item thresholds across age, family income, HbA1c, racial category, gender, and illness duration.

CONCLUSIONS

The results support initial evidence of equitable assessment, measurement invariance, validity, and reliability for SCI-SF6 across important socio-illness-demographic variables.

Type 1 diabetes presenting in adults: Trends, diagnostic challenges and unique features

Type 1 diabetes (T1D) has been historically regarded as a childhood-onset disease; however, recent epidemiological data indicate that adult-onset T1D accounts for a substantial proportion of cases worldwide. There is evidence that adult-onset T1D is associated with the classic T1D triad of elevated genetic risk, the presence of islet-specific autoantibodies and progression to severe insulin deficiency. In this article, we review our understanding of the commonalities and differences between childhood and adult-onset T1D, and we highlight significant knowledge gaps in our understanding of the diagnosis, incidence, trajectory and treatment of adult-onset T1D. Compared to children, adults presenting with T1D exhibit differences in genetic risk, immunologic profiles and metabolic outcomes, including differences in the type and number of autoantibodies present, genetic associations and total genetic burden, rates of C-peptide decline, the persistence of C-peptide in long-duration disease and glycaemic control. In addition, obesity and metabolic syndrome are increasingly common in adults, which not only blurs the clinical distinction of adult-onset T1D from type 2 diabetes (T2D) but also likely contributes to differences in metabolic outcomes and rates of progression. Because T2D is so prevalent in the adult population, adult-onset T1D is misclassified as T2D in at least one in three cases, leading to delays in appropriate treatment. Current diagnostic tools, including autoantibody testing and C-peptide measurement, are underutilised or lack specificity in distinguishing adult-onset T1D from atypical T2D. Additionally, the impact of different responses to disease-modifying therapy between adults and children is unclear. Addressing these knowledge gaps requires expanded epidemiological studies, diverse patient registries and refined classification criteria to improve early detection and treatment strategies. A deeper understanding of adult-onset T1D will be critical to reduce the burden of misdiagnosis, lead to earlier diagnosis and treatment and optimise population-based screening approaches in this under-recognised population. PLAIN LANGUAGE SUMMARY: Type 1 diabetes (T1D) is an autoimmune disease that causes metabolic and nutritional complications due to the destruction of insulin-producing pancreatic β cells. T1D was formerly known as "juvenile diabetes" because it was assumed that most cases occurred in childhood; however, recent epidemiological data show that nearly half of all T1D cases are diagnosed in adulthood. Despite the high prevalence of adult-onset T1D, there are challenges with correctly diagnosing T1D in adulthood, and significant knowledge gaps remain regarding the incidence, trajectory, and treatment of adult-onset T1D. In this article, we summarize the current understanding of commonalities and differences between childhood and adult-onset T1D. Particularly, we highlight age-related differences in genetic risk, immunologic profiles, and metabolic outcomes and complications. Finally, we highlight key gaps in our understanding of adult-onset T1D that need to be addressed to reduce the burden of misdiagnosis and allow for better screening and treatment of T1D in adulthood.

Hybrid Closed Loop in Adolescents and Young Adults Living with Type 1 Diabetes: A Real-World Study

To evaluate the long-term metabolic outcomes and safety of hybrid closed loop (HCL) in youth living with type 1 diabetes, including people with very poor metabolic control, this observational, retrospective, monocentric study included 101 patients aged 15-25 years. After a mean (±standard deviation; range) follow-up of 16 (±6; 3-31) months, HbA1c decreased from 9.6% ± 2.3% (82 ± 25 mmol/mol) at baseline to 8.0% ± 1.4% (64 ± 15 mmol/mol) (P < 0.001). Continuous glucose monitoring parameters showed the same trend (P < 0.001): the glucose management indicator decreased from 8.8% to 7.9%, time in range increased from 39% to 57%, and time below range decreased from 3.0% to 1.6%. Ten patients discontinued HCL. There was no more severe hypoglycemia or diabetes ketoacidosis under HCL compared with the year before HCL initiation. Five cases of new onset and four cases of worsening retinopathy were reported. Youth with type 1 diabetes can improve metabolic control thanks to HCL without increasing complication risk. Vigilance is required for preexisting retinopathy monitoring.

Efficacy of automated insulin delivery systems in people with type 1 diabetes: a systematic review and network meta-analysis of outpatient randomised controlled trials

Background

The comparative efficacy of automated insulin delivery (AID) systems and other treatment options for type 1 diabetes, accounting for the certainty of evidence (CoE), is unknown.

Methods

We searched PubMed, EMBASE, the Cochrane Central Register of Controlled Trials and ClinicalTrials.gov and included outpatient randomised controlled trials (RCTs) published until January 8, 2025, in people with type 1 diabetes with a three-week or longer intervention of AID systems (PROSPERO registration number: CRD42023395492). We performed pairwise and network meta-analyses and used the Risk of Bias tool 2 and the Grading of Recommendations Assessment, Development and Evaluation methods to determine the CoE for each outcome.

Findings

A total of 46 studies involving seven insulin treatment options and 4113 participants were included, of which 29 and 17 had low and moderate risks of bias, respectively. The intervention AID systems, including the hybrid closed-loop (HCL), advanced HCL (AHCL) and full closed-loop (FCL) systems, were evaluated in 20, 25 and 1 studies, respectively. The network meta-analysis did not indicate global inconsistencies but did indicate global publication bias for all glycaemic outcomes. The CoE varied between very low and high, depending on the treatment and outcome under consideration. Compared with pump therapy, the percentage of time in the range 70-180 mg/dl was greater with AID use (HCL: 19.7% [95% confidence interval 13.2%; 26.1%], moderate CoE; AHCL: 24.1% [18.2%; 29.9%], moderate CoE; FCL: 25.5% [11.1%; 39.9%], high CoE). Compared with pump therapy, the percentage of time above 180 mg/dl and 250 mg/dl was lower with AHCL, on average, by 19.6% (14.0%; 25.1%), moderate CoE, and 14.8% (8.8%; 20.8%), moderate CoE, respectively. The CoE was very uncertain regarding the overall effect of AID systems on the percentage of time below 70 mg/dl and 54 mg/dl and the HbA1c.

Interpretation

AID systems improve glycaemic outcomes to varying degrees and with varying CoE.

Funding

German Federal Ministry of Education and Research (BMBF; grant 01KG2203).

Longitudinal Determination of Diabetes Complications and Other Clinical Variables as Risk Factors for Diabetic Ketoacidosis in Type 1 Diabetes

OBJECTIVE

We aimed to determine whether diabetes complications, such as kidney disease that may impair acid-base buffering capacity, independently predict the risk of subsequent diabetic ketoacidosis (DKA).

RESEARCH DESIGN AND METHODS

We accessed previously collected 34-year data from the Diabetes Control and Complications Trial and Epidemiology of Diabetes Interventions and Complications study through public data access. Multivariable Cox proportional hazards models with time-varying exposures and covariates were used to examine the associations of macrovascular disease and early and late stages of neuropathy, nephropathy, and retinopathy, with subsequent DKA occurrence as the outcome.

RESULTS

Of 1,441 participants, 297 experienced 488 DKA events over follow-up. Major adverse cardiovascular events [hazard ratio (HR) 3.16, 95% CI 1.57-6.35, P = 0.001] and late-stage neuropathy, which comprised serious foot ulcer or amputation (HR 1.59, 95% CI 1.04-2.45, P = 0.03) were independently associated with higher DKA risk. Higher risk was also associated with shorter diabetes duration (HR 0.76, 95% CI 0.64-0.91, P = 0.002), female sex (HR 2.04, 95% CI 1.56-2.67, P < 0.001), current insulin pump use (HR 3.04, 95% CI 2.29-4.02, P < 0.001), higher time-updated HbA1c (per additional 1%: HR 1.39, 95% CI 1.29-1.50, P < 0.001), and higher current insulin dose (per 1 additional unit/kg/day: HR 2.32, 95% CI 1.62-3.33, P < 0.001).

CONCLUSIONS

A major cardiovascular event, foot ulcer, or amputation confers the greatest risk of future DKA independent of previously recognized risk factors, implying a need to target patients with these events for DKA prevention interventions, such as self-management skills for metabolic control, management of depression, and DKA education.

Predictors of glycaemic improvement in children and young adults with type 1 diabetes and very elevated HbA1c using the MiniMed 780G system

AIMS

This study aimed to identify key factors with the greatest influence on glycaemic outcomes in young individuals with type 1 diabetes (T1D) and very elevated glycaemia after 3 months of automated insulin delivery (AID).

MATERIALS AND METHODS

Data were combined and analysed from two separate and previously published studies with similar inclusion criteria assessing AID (MiniMed 780G) efficacy among young individuals naïve to AID (aged 7-25 years) with glycated haemoglobin A1c (HbA1c) ≥69 mmol/mol (≥8.5%). Univariate and multivariate linear models were performed to explore factors leading to the greatest improvements in HbA1c and time in range 3.9-10.0 mmol/L (70-180 mg/dL; TIR).

RESULTS

A total of 99 young individuals (aged 17.3 ± 4.2 years; baseline HbA1c 92 ± 21 mmol/mol [10.6% ± 1.9%]) were included. After 3 months of AID use, HbA1c improved to 65 ± 16 mmol/mol (8.1% ± 1.5%) (-27 ± 23 mmol/mol; -2.5% ± 2.1% change), and TIR improved from 24.2% ± 13.5% to 58.4% ± 15.4% (p both <0.001). In the multivariate analysis, two key factors for both HbA1c and TIR improvement were identified: high baseline HbA1c (>100 mmol/mol [>11.0%]) and high time in automation mode (>80%), which led to decreased HbA1c by 27.0 mmol/mol (2.4%) and 14.2 mmol/mol (1.3%) and increased TIR by 6.1% and 11.1% (p all <0.05) respectively. Meal announcement frequency >3 times/day and glucose target of 5.5 mmol/L (100 mg/dL) also led to significant increases in TIR. No other factors, including age, prior use of multiple daily injection, ethnicity, gender and optimal active insulin time 2 h, contributed to statistically significant HbA1c or TIR improvement.

CONCLUSIONS

In young individuals naive to AID, those with the highest baseline HbA1c and high percentage time in automation experience the greatest benefits after initiation of AID. Sociodemographic background and carbohydrate counting adherence/knowledge should not prevent or delay access to AID technology (ACTRN12621000556842 and ACTRN12622001454763).

Evaluating the impact of severe hypoglycaemia definition wording on severe hypoglycaemia history assessment

AIM

Several wordings of the definition of severe hypoglycaemia (SH) exist. This study aims to evaluate how different SH definition wordings affect SH history assessment.

METHODS

In this cross-sectional study, surveys were emailed to registrants of the T1D Exchange, a U.S. national type 1 diabetes patient registry. Participants' demographic information was collected. Six-month SH history was evaluated with questionnaires including SH definition wordings from either (1) professional societies, (2) a diabetes community website, or (3) a hypoglycaemia research questionnaire. Analyses included the McNemar test, pairwise Wilcoxon signed-rank test, logistic regression analysis, Kappa statistics, and Spearman correlation.

RESULTS

A total of 1580 valid responses were obtained from participants (52% female; mean ± SD age: 46 ± 15 years; 95% White; mean ± SD diabetes duration: 25 ± 16 years). Questionnaires with four different SH definition wordings yielded significant variations in the prevalence of SH (i.e., having developed at least one episode of SH) and the number of SH episodes: the ADA/ENDO 2013 definition wording yielded the highest results on both metrics, whereas HypoA-Q and ADA 2023 yielded the lowest. Among participants reporting at least one SH episode, the number of episodes identified with the different SH definition wordings was poorly correlated (Rs: 0.09-0.37; p < 0.001). Race, education level, and household income were associated with higher odds of discrepancies in SH history (p < 0.05).

CONCLUSION

This U.S. national survey with individuals living with type 1 diabetes demonstrated significant discrepancies in SH history when assessed with different SH definition wordings. Race and socioeconomic status were associated with these discrepancies.

Glycemic variability and weight-focused eating behaviors among adolescents and young adults with type 1 diabetes†

OBJECTIVE

Type 1 diabetes (T1D) disease management and associated glycemic fluctuations can disrupt experiences of hunger and satiety, which may increase risk for disordered eating behaviors. Glycemic variability may be a useful trigger for just-in-time interventions for disordered eating behaviors. In this exploratory study, we hypothesized that two metrics of glycemic variability would be associated with greater hunger and predict eating behaviors for weight loss or maintenance in adolescents and young adults with T1D.

METHODS

Individuals with T1D were recruited from a university diabetes clinic (N = 34; 50% female, Mage = 19.53 years, MHbA1c = 7.98%; 29% Hispanic/Latinx; 79% White). Participants wore a blinded continuous glucose monitor for 5 days, and completed ecological momentary assessments (four prompts per day) that included measures of hunger and eating behaviors for weight loss or maintenance purposes. Generalized and linear mixed models were used to test hypotheses.

RESULTS

Approximately 30% of participants were at risk for an eating disorder based on Diabetes Eating Problem Survey-Revised scores. Greater glycemic variability did not predict hunger, but was associated with increased odds of endorsing any eating behavior for weight loss or maintenance purposes within-person (ps<.05). Greater hunger was associated with increased odds of endorsing disordered eating behavior within-person (p<.05).

CONCLUSIONS

This exploratory study provides some preliminary evidence that times of greater hunger and glycemic variability may be when individuals with T1D may be at higher risk of engaging in behaviors to lose or maintain weight.

Patient Characteristics Associated With Annual Nutrition Visits in Children With Type 1 Diabetes

Objective

Diabetes organizations recommend nutrition education by a registered dietitian (RD) at least annually following type 1 diabetes (T1D) diagnosis in children. The study objectives were to describe differences over time in annual RD follow-up in children with T1D and to identify patient characteristics associated with RD engagement.

Research Design and Methods

Data based on 6034 completed diabetes medical visits among 1982 patients aged <18 years with T1D for ≥1 year followed at a pediatric, tertiary care, academic medical center over a 5-year period (2018-2022) were analyzed. Generalized estimating equations models assessed for differences over time in the rates of RD visit completion in the year preceding the last diabetes medical encounter and identified sociodemographic, diabetes care-related, and clinical patient characteristics associated with RD follow-up. Models were fit for the whole sample and groups subset by race and ethnicity.

Results

Observed annual RD follow-up rate over the 5-year period was 20.8%, with the lowest adjusted percentage in 2021 compared to 2018. In multivariable analysis, for each year increase in age (p = 0.004) and diabetes duration (p<0.001), there was a 3% and 15% reduction in the odds of RD follow-up, respectively. RD follow-up was associated with lower hemoglobin A1c within the subsequent year in adjusted analysis (p = 0.029), with the greatest improvement among Hispanic patients.

Conclusions

Annual RD visit frequency among children with T1D is suboptimal. Study findings provide insights for targeted intervention to improve RD engagement. RD follow-up may be associated with improved glycemic outcomes.

Technology Use and Diabetes Management Across Elder Age Groups in Type 1 Diabetes and Latent Auto-Immune Diabetes of the Adult (LADA), a BETTER Registry Cross-Sectional Analysis

OBJECTIVES

Real-world data on diabetes management among a heterogenous aging population remain limited. This study aims to provide an overview of technology use and factors associated to its use, diabetes management and psychosocial aspects experienced by adults aged 50 and over living with type 1 diabetes (T1D) or latent autoimmune diabetes in adults (LADA).

METHODS

This cross-sectional study analyzed data from the Canadian BETTER registry, mostly based on self-reported outcomes from individuals living with T1D or LADA. Comparative analyses were conducted across three age groups: 50-59, 60-69, and ≥70.

RESULTS

Participants (n=674) were predominantly Caucasian (97-98% across groups) and residing in Quebec, Canada (71-79%). Insulin pump use was similar across age groups (36-39%, p=0.822), while continuous glucose monitoring (CGM) was lower among those aged ≥70 years (85% for both 50-59 and 60-69 vs 73% for ≥70 years, p=0.020). Among other factors, having private insurance and living outside of Quebec were positively associated with both insulin pump and CGM use. A high proportion (80-86%) of participants achieved an HbA1c ≤8% across all groups. Level 2 hypoglycemia events in the last month were more frequent among participants aged 50-59 years compared to those aged ≥70 years (6.9 vs 3.4, p=0.001). Level 3 hypoglycemia, social and professional support were similar between groups. Interestingly, diabetes-related distress was lower in older age groups.

CONCLUSIONS

Most individuals in this cohort adopted technology use but in lower proportion among the group aged ≥70. Overall, diabetes management was good and similar between age groups.

An Exergames Program for Adolescents with Type 1 Diabetes: A Qualitative Study of Acceptability

BACKGROUND

Numerous barriers to moderate and vigorous physical activity (MVPA) exist for youth with type 1 diabetes (T1D). The virtual exercise games for youth with T1D (ExerT1D) intervention implements synchronous support of MVPA including T1D peers and role models.

OBJECTIVE

To understand the acceptability of this intervention to participants.

METHODS

We conducted post-program, semi-structured, televideo interviews with participating youth to elicit perspectives on acceptability of the intervention and experience with the program. Two coders independently reviewed and analyzed each transcript using a coding scheme developed inductively by senior researchers. Discrepancies were resolved by team discussion, and multiple codes were grouped together to produce four main thematic areas.

RESULTS

All 15 participants provided interviews [14-19 years old; 2 non-binary, 6 females; 7.8% median HbA1c, 5 with HbA1c≥10.0%]. Qualitative data revealed four themes. (1) Motivation to engage in PA: Improving their physical capabilities and/or stabilizing glucose levels were cited as motivation for PA. Challenges of living with T1D were cited as PA barriers. (2) Experience with and motivation to manage diabetes while engaging in PA: Participants provided details of accommodating the inherent uncertainty or limitations of PA with diabetes. Sometimes preparing for PA involved psychological and motivational adjustments. Some relayed feelings of avoidance. (3) Peer support encouraged engagement with the intervention: Participants appreciated the peer aspects of components of ExerT1D. Participants' reflections of the facilitated group experience highlight many benefits of a small-group virtual program. (4) Improvements in PA and diabetes self-management efficacy: All participants credited the program with improving and/or raising awareness of T1D management skills.

CONCLUSIONS

Our virtual PA intervention using an active video game and discussion component provided adolescents with T1D the confidence and peer support to engage in PA, improve awareness of diabetes-specific tasks to prepare for exercise, and improved understanding of the effect of PA on glucose levels. Engaging youth with a virtual videogame intervention is a viable approach to overcome barriers to PA for adolescents with T1D.

CLINICALTRIAL

Interviewed participants of clinical trial NCT05163912.

Pharmacist Integration to Support Continuous Glucose Monitoring Initiation: A Collaborative, Patient-Centered Approach

Objective: The development of continuous glucose monitoring (CGM) has allowed for improved glycemic control among patients with diabetes. Clinical pharmacists possess medication expertise and can provide support for increased CGM utilization through device education and affordability assistance, but there is limited evidence evaluating the effectiveness of clinical pharmacist-assisted CGM initiation. The objective of this study was to examine how clinical pharmacist-assisted CGM implementation can impact glycemic control for patients with diabetes. Methods: This is a retrospective pre-post study that evaluated change in A1c among patients who were assisted with CGM device implementation by a clinical pharmacist between January 1, 2019, and December 31, 2023. The primary outcome of this study was change in A1c from baseline (prior to CGM initiation) to the next subsequent A1c following CGM initiation. The study team also investigated change in A1c among a subgroup of patients followed independently by clinical pharmacists practicing under a collaborative drug therapy management (CDTM) agreement. Results: Pharmacist-assisted CGM initiation led to a statically significant decrease in mean A1c of -0.71 (CI 95% 0.41-1.00, P < 0.001) across all patients. Within the CDTM subgroup, the mean A1c difference was -1.60 (CI 95% 0.64-2.55, P = 0.002) while in the non-CDTM subgroup, the mean A1c difference was -0.50 (CI 95% 0.22-0.78, P < 0.001). Conclusions: Clinical pharmacists are effective at helping patients with diabetes reduce their A1c through assisting with CGM initiation, education, and follow-up. Among patients included in this study, those followed by pharmacists practicing under CDTM agreements saw the greatest amount of A1c reduction.

Demographic variation in continuous glucose monitoring utilisation among patients with type 1 diabetes from a US regional academic medical centre: a retrospective cohort study, 2018-2021

OBJECTIVE

While continuous glucose monitoring (CGM) utilisation has been increasing among patients with type 1 diabetes (T1D), few studies have examined patterns of use across age, race/ethnicity and insurance status together. In this study, we examine CGM utilisation among patients with T1D from a regional academic medical centre across all insurance types.

DESIGN AND SETTING

This is a retrospective cohort study including both paediatric and adult patients with T1D who visited a regional academic medical centre between 1 January 2018 and 31 December 2021.

METHODS

Patients were followed from the date of their first T1D encounter during the study period until the first of the following: CGM use was documented, ≥730 days with no encounters at this centre or the end of the study period. We compared CGM use across demographic and clinical characteristics and used logistic regression models to assess the association between demographic variables and CGM utilisation.

RESULTS

Among 3311 eligible patients with T1D, CGM utilisation was 51.22%. The highest utilisation rates were among patients <18 years old while the lowest rates were among those in the 65+ years age group. Patients with private insurance and those who attended diabetes self-management education and support (DSMES) programmes had significantly higher CGM utilisation than those with public insurance and those who did not attend DSMES, respectively. In models stratified by age, we examined patterns of CGM use across insurance categories and found that CGM rates were persistently low among those with public versus private insurance.

CONCLUSIONS

In this retrospective review of patients with T1D receiving care at a regional academic medical centre from 2018 to 2021, nearly half of our sample used CGM. However, we found substantial variation in CGM utilisation with lower rates among older versus younger adults and individuals covered by public versus private insurance. Enhancing CGM access is important to mitigate diabetes-related complications for all patients with T1D.

Adipose stromal cells increase insulin sensitivity and decrease liver gluconeogenesis in a mouse model of type 1 diabetes mellitus

BACKGROUND

Diabetic ketoacidosis (DKA) is a serious complication of hyperglycemic emergency caused by insulin deficiency through accelerated liver gluconeogenesis and glycogenolysis. DKA is most common in type 1 diabetes (T1D). Transplantation of islet cells and pancreas is an alternative to insulin injection for treating T1D. However, this alternative is only suitable for some patients. This study investigated the effects and mechanisms of adipose stromal vascular fraction (SVF) cells on liver gluconeogenesis and insulin sensitivity in an insulin-dependent T1D animal model.

METHODS

SVF cells were obtained from wild-type inguinal adipose tissue and transplanted into the peritoneal cavity of type I diabetic Akita (Ins2Akita) mice.

RESULTS

We found that transplantation of 5 × 106 SVF cells from wild-type adipose tissue significantly downregulated proinflammatory genes of TNF-α, IL-1β, IL-33, iNOS, and DPP4 in the liver and upregulated anti-inflammatory factors IL-10 and FOXP3 in blood serum and liver tissue 7 days after injection. Moreover, we found that the expression levels of G6pc and Pck1 were significantly decreased in the Akita mice livers. Furthermore, the intraperitoneal insulin tolerance test assay showed that diabetic Akita mice significantly had increased insulin sensitivity, reduced fasting blood glucose, and restored glucose-responsive C-peptide expression compared with the control Akita group. This result was noted 14 days after administration of 5 × 106 or 1 × 107 SVF cells from wild-type adipose tissue into diabetic Akita mice.

CONCLUSIONS

Together, these findings suggest that adipose tissue-derived SVF cells could suppress liver inflammation, regulate liver gluconeogenesis, and improve insulin sensitivity in an animal model with T1D. Therefore, adipose SVF cells may be novel cellular therapeutic alternatives to maintain steady liver gluconeogenesis in T1D.

Metabolic interventions as adjunctive therapies to insulin in type 1 diabetes: Current clinical landscape and perspectives

Type 1 diabetes (T1D) is classically characterized as an autoimmune disease wherein the immune system erroneously attacks insulin-producing pancreatic β-cells, causing insulin insufficiency and severe metabolic dysregulation. However, intensive investigation and numerous clinical trials with immunotherapies have been largely unable to significantly alter the course of disease. Currently, there is no effective way to prevent or cure T1D, and insulin remains the cornerstone of T1D treatment. In recent years, a growing body of research suggests that β-cells actively contribute to the immune response and to disease development. Factors including glucotoxicity, lipotoxicity, inflammation, endoplasmic reticulum (ER) and oxidative stress can induce β-cell apoptosis and senescence, further promoting insulitis. Recent studies highlight the importance of targeting metabolic control for T1D management and treatment. Metabolic interventions, through their direct and indirect impacts on β-cells, have shown promise in preserving β-cell function. These interventions can reduce glucose toxicity, alleviate oxidative stress and inflammation, enhance insulin sensitivity, and indirectly mitigate the autoimmune responses. By preserving β-cell function, individuals with T1D attain better glycaemic control, reduced complication risks and exhibit improved overall metabolic health. Here, we provide an overview of insights from clinical studies, systematic reviews and meta-analyses that collectively demonstrate that adjunctive metabolic interventions can enhance glycaemic control, reduce insulin requirements and mitigate adverse effects associated with insulin monotherapy. They also show potential for halting disease progression, preserving residual β-cell function and improving long-term outcomes for newly diagnosed individuals. Future research should focus on optimizing these treatment strategies and establishing their long-term efficacy and safety.

Efficacy and Safety of Tirzepatide in Adults With Type 1 Diabetes: A Proof of Concept Observational Study

BACKGROUND

Tirzepatide is approved by the United States Food and Drug Administration (FDA) for the management of type 2 diabetes. The efficacy and safety of this drug have not been studied in people with type 1 diabetes (T1D).

METHODS

In this single-center, retrospective, observational study, hemoglobin A1c (HbA1c), weight, body mass index (BMI), and continuous glucose monitoring (CGM) data were collected from electronic health records of adults with T1D at initiation of tirzepatide and at subsequent clinic visits over 8 months. Primary outcomes were reduction in HbA1c and percent change in body weight and secondary outcomes were change in CGM metrics and BMI over 8 months from baseline.

RESULTS

The mean (±SD) age of the 26 adults (54% female) with T1D was 42 ± 8 years with a mean BMI of 36.7 ± 5.3 kg/m2. There was significant reduction in HbA1c by 0.45% at 3 months and 0.59% at 8 months, and a significant reduction in body weight by 3.4%, 10.5%, and 10.1% at 3, 6, and 8 months after starting tirzepatide. Time in target range (TIR = 70-180 mg/dL) and time in tight target range (TITR = 70-140 mg/dL) increased (+12.6%, P = .002; +10.7%, P = .0016, respectively) and time above range (TAR >180 mg/dL) decreased (-12.6%, P = .002) at 3 months, and these changes were sustained over 8 months. The drug was relatively safe and well tolerated with only 2 patients discontinuing the medication.

CONCLUSIONS

Tirzepatide significantly reduced HbA1c and body weight in adults with T1D. A randomized controlled trial is needed to establish efficacy and safety of this drug in T1D.

Initiating Insulin Pumps in Youth with New-onset Type 1 Diabetes: A Quality Improvement Initiative

Introduction

Insulin pump therapy is recommended for youth with type 1 diabetes (T1D) as it enhances quality of life and improves glycemic management. We led a quality improvement initiative to increase insulin pump use in youth younger than 18 years of age with recently diagnosed T1D (duration <1 y) from a baseline of 17% to 27% from January 2021 to December 2023. As a balancing measure, we evaluated the diabetes-related ketoacidosis (DKA) rate in the same cohort as nonpump users.

Methods

We implemented the following plan-do-study-act cycles: (1) development and implementation of pump initiation algorithm, including minimal safe start criteria and education on ketosis management with pump action plan, (2) establishing clinic follow-up within 90 days of pump start, (3) expansion of the pump algorithm at additional clinic locations, (4) early patient/caregiver education about pumps at a clinic visit 2 weeks after diagnosis, and (5) insulin pump therapy workshop for staff and providers.

Results

There was a centerline shift in the percentage of patients with recently diagnosed T1D on insulin pumps from 17% to 28% from January 2021 to December 2023. We also found no pumps-related DKA encounters amongst patients with recently diagnosed T1D.

Conclusions

Our improvement efforts increased pump usage in our cohort without related DKA events. A multidisciplinary approach with education on managing pumps should be implemented to prevent shortcomings such as DKA. Future directions are to evaluate HbA1c and pre-pump and post-pump DKA rates.

European Survey on Adult People With Type 1 Diabetes and Their Caregivers: Insights into Perceptions of Technology

BACKGROUND

Type 1 diabetes (T1D) is a complex condition requiring constant monitoring and self-management. The landscape of diabetes management is evolving with the development of new technologies. This survey aimed to gain insight into the perceptions and experiences of people with T1D (PWD) and their caregivers on the use of technology in diabetes care, and identify future needs for T1D management.

METHODS

PWD and caregivers (≥18 years) living in five European countries (France, Germany, Italy, Spain, and the United Kingdom) completed an online survey. Data were collected during July and August 2021.

RESULTS

Responders included 458 PWD and 54 caregivers. More than 60% of PWD perceived devices/digital tools for diabetes management as useful and 63% reported that access to monitoring device data made their life easier. Nearly half of participants hoped for new devices and/or digital tools. While approximately one-third of all PWD had used teleconsultation, perceptions and usage varied significantly between countries and by age (both P < .0001), with the lowest use in Germany (20%) and the highest in Spain (48%). The proportions of PWD contributing to diabetes care costs varied by device and were highest for smart insulin pen users at 83% compared with 44% for insulin pen users and 37% for insulin pump users. One-quarter (24%) of PWD and 15% of caregivers felt they lacked knowledge about devices/digital tools for T1D.

CONCLUSIONS

Most PWD and caregivers had positive perceptions and experiences of new technologies/digital solutions for diabetes management, although improved support and structured education for devices/digital tools are still required.

Expectations and Outcomes From Glucagon-Like Peptide-1 Receptor Agonists As Adjunct Treatment for Type 1 Diabetes - Case Presentations

BACKGROUND

Type 1 diabetes (T1D) is characterized by the autoimmune destruction of pancreatic beta cells, leading to lifelong insulin dependence. Despite advancements in insulin therapies and glucose monitoring, maintaining optimal blood glucose control remains challenging with common issues like weight gain and glucose variability. Glucagon-like peptide 1 receptor agonists (GLP-1 RAs), approved for type 2 diabetes and obesity, are being explored off-label for T1D.

CASE REPORT

This case series investigates the effectiveness of GLP-1 RAs, mainly semaglutide and tirzepatide, as an adjunct therapy to insulin in adolescents and young adults (AYA) with T1D, in a single center, providing real-world insights and highlighting practical issues.

DISCUSSION

Most patients had obesity, consistent with typical indication for use in AYA. Common gastrointestinal side effects improved with dose titration, but careful monitoring is needed for persistent symptoms. One patient developed an eating disorder, underscoring the need for vigilance. Insurance and medication shortage issues impacted treatment continuity, highlighting the need for better support. Glycemic parameters improved in most patients, with weight reduction in several patients with obesity, and no reported diabetic ketoacidosis.

CONCLUSIONS

GLP-1 RAs can be a beneficial adjunct therapy in T1D, improving glycemic control, reducing insulin needs, and supporting weight management, while potentially preventing long-term cardiovascular and renal complications.

Telehealth occupational therapy improves psychosocial well-being but not glycemia among young adults with type 1 diabetes: The Resilient, Empowered, Active Living-Telehealth (REAL-T) randomized controlled trial

BACKGROUND

Young adults with type 1 diabetes mellitus often face challenges managing their condition, leading to elevated glucose and heightened psychosocial distress. Diabetes care traditionally focuses on biomedical outcomes, with less emphasis on well-being. Occupational therapy offers a holistic approach to managing diabetes by integrating changes to daily habits and routines and psychosocial support.

METHODS

This randomized controlled trial involved participants aged 18-30 with HbA1c ≥ 7.5 % (≥58 mmol/mol). Participants received either telehealth occupational therapy or usual care. The intervention addressed diabetes management, daily habits and routines, and emotional well-being. Data collected at baseline, 3 months, and 6 months included HbA1c, continuous glucose monitoring metrics, and psychosocial outcomes. Analyses employed intent-to-treat principles, using ANCOVA to evaluate between-group differences.

RESULTS

Participants (n = 209) were 24.3 (±3.7) years old, 59.8 % female, 44.5 % non-Hispanic White, and 47.4 % publicly insured. No significant differences were found in glycemic outcomes. Intervention participants had improved diabetes-related quality of life (DQoL; least-squares [LS] mean 0.67, 95 % CI 0.02 to 1.32, p = 0.045) and reduced diabetes distress (LS-mean -0.36, CI -0.65 to -0.07, p = 0.01).

CONCLUSION

Generalizability may be impacted by external factors related to COVID-19. The findings suggest occupational therapy may be beneficial for young adults experiencing diabetes-related distress and poor DQoL.

A Randomized Trial Comparing Inhaled Insulin Plus Basal Insulin Versus Usual Care in Adults With Type 1 Diabetes

OBJECTIVE

To evaluate a regimen of inhaled Technosphere insulin (TI) plus insulin degludec in adults with type 1 diabetes, who prestudy were predominately using either an automated insulin delivery (AID) system or multiple daily insulin injections (MDI) with continuous glucose monitoring.

RESEARCH DESIGN AND METHODS

At 19 sites, adults with type 1 diabetes were randomly assigned to TI plus insulin degludec (N = 62) or usual care (UC) with continuation of prestudy insulin delivery method (N = 61) for 17 weeks.

RESULTS

Prestudy, AID was used by 48% and MDI by 45%. Mean ± SD HbA1c was 7.57% ± 0.97% at baseline and 7.62% ± 1.06% at 17 weeks in the TI group and 7.59% ± 0.80% and 7.54% ± 0.77%, respectively, in the UC group (adjusted difference 0.11%, 95% CI -0.10 to 0.33, P value for noninferiority = 0.01). HbA1c improved from baseline to 17 weeks by >0.5% (5.5 mmol/mol) in 12 (21%) in the TI group and in 3 (5%) in the UC group and worsened by >0.5% (5.5 mmol/mol) in 15 (26%) in the TI group and in 2 (3%) in the UC group. The most common TI side effect was a brief cough; eight participants discontinued TI due to side effects.

CONCLUSIONS

In adults with type 1 diabetes, HbA1c after 17 weeks with a regimen of TI and degludec was noninferior to UC, which consisted predominately of either AID or MDI. TI should be considered an option for people with type 1 diabetes, particularly those who are motivated to further reduce postprandial hyperglycemia.

Efficacy and Safety of Automated Insulin Delivery Systems in Patients with Type 1 Diabetes Mellitus: A Systematic Review and Meta-Analysis

BACKGRUOUND

Automated insulin delivery (AID) systems studies are upsurging, half of which were published in the last 5 years. We aimed to evaluate the efficacy and safety of AID systems in patients with type 1 diabetes mellitus (T1DM).

METHODS

We searched PubMed, Embase, Cochrane Library, Web of Science, and ClinicalTrials.gov until August 31, 2023. Randomized clinical trials that compared AID systems with other insulin-based treatments in patients with T1DM were considered eligible. Studies characteristics and glycemic metrics was extracted by three researchers independently.

RESULTS

Sixty-five trials (3,623 patients) were included. The percentage of time in range (TIR) was 11.74% (95% confidence interval [CI], 9.37 to 14.12; P<0.001) higher with AID systems compared with control treatments. Patients on AID systems had more pronounced improvement of time below range when diabetes duration was more than 20 years (-1.80% vs. -0.86%, P=0.031) and baseline glycosylated hemoglobin lower than 7.5% (-1.93% vs. -0.87%, P=0.033). Dual-hormone full closed-loop systems revealed a greater improvement in TIR compared with hybrid closed-loop systems (-19.64% vs. -10.87%). Notably, glycemia risk index (GRI) (-3.74; 95% CI, -6.34 to -1.14; P<0.01) was also improved with AID therapy.

CONCLUSION

AID systems showed significant advantages compared to other insulin-based treatments in improving glucose control represented by TIR and GRI in patients with T1DM, with more favorable effect in euglycemia by dual-hormone full closedloop systems as well as less hypoglycemia for patients who are within target for glycemic control and have longer diabetes duration.

The Effect of Nutrition Education on Glycemic Outcomes in People With Type 1 Diabetes Initiating the Use of Glucose Sensors

AIM

To determine whether people with type 1 diabetes (T1D) initiating glucose sensor monitoring experience greater improvements in HbA1c when provided with education on carbohydrate counting and flexible insulin dosing than those who do not receive nutrition education.

MATERIALS AND METHODS

Our retrospective observational study included 329 people with T1D initiating glucose sensor monitoring between 2015 and 2021. The participants were divided into two groups: one group attended at least one structured educational session with a registered dietitian (n = 126), while the other group did not receive structured education (n = 203). After 12 months of glucose sensor initiation, we compared glycaemic outcomes and CGM metrics between the two groups.

RESULTS

At glucose sensor initiation, both groups with and without education had similar HbA1c levels (7.64% [60.0 mmol/mol] vs. 7.66% [60.2 mmol/mol]). After twelve months, the education group demonstrated greater improvement in glycemic outcomes (HbA1c 7.17% [54.9mmol/mol] vs. 7.37% [57.1 mmol/mol], p < 0.05) and spent significantly more time in the target range than did the group without structured education (68.8% vs. 64.1%, p < 0.05). We observed an inverse correlation between the number of completed educational sessions and HbA1c after 12 months, as well as between the number of educational sessions and the change in HbA1c.

CONCLUSIONS

People with T1D who initiated glucose sensor monitoring alongside nutrition education showed greater improvements in HbA1c and increased time spent in the target glucose range compared to individuals who did not receive structured education.

TRAIL REGISTRATION

ClinicalTrials.gov identifier: NCT06264271.

The Promise of Adjunct Medications in Improving Type 1 Diabetes Outcomes: Glucagon-Like Peptide Receptor Agonists

Type 1 diabetes (T1D) necessitates lifelong insulin therapy due to the autoimmune destruction of insulin-producing pancreatic beta cells. Despite advancements in diabetes technology and insulin formulations, maintaining optimal glycemic outcomes remains challenging in these individuals. Obesity, accompanied by insulin resistance, is common not only in type 2 diabetes (T2D) but also in many individuals with T1D. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs), approved for T2D and obesity, are now being explored for off-label use in individuals with T1D. This review examines their efficacy, safety, and potential benefits in T1D management. We reviewed articles published up to May 2024 from databases like PubMed and Scopus, mainly focusing on human studies of GLP-1 RAs in T1D, as well as cardiorenal and metabolic outcomes in individuals with T2D and obesity. Semaglutide and other GLP-1 RAs showed significant improvements in glycemic outcomes, hemoglobin A1c levels, reduced insulin doses, and notable weight loss. Studies in individuals with obesity and T2D showed significant improvements in lipid profile and offered cardiorenal protection. Common side effects include gastrointestinal issues, and while some studies reported hypoglycemia, hyperglycemia, and ketosis, others did not. Despite these challenges, GLP-1 RAs offer significant therapeutic benefits, making them a promising adjunct to insulin therapy for improving clinical outcomes in T1D management.

The Effect of Do-It-Yourself Real-Time Continuous Glucose Monitoring on Glycemic Variables and Participant-Reported Outcomes in Adults With Type 1 Diabetes: A Randomized Crossover Trial

AIM

Real-time continuous glucose monitoring (rtCGM) has several advantages over intermittently scanned continuous glucose monitoring (isCGM) but generally comes at a higher cost. Do-it-yourself rtCGM (DIY-rtCGM) potentially has benefits similar to those of rtCGM. This study compared outcomes in adults with type 1 diabetes using DIY-rtCGM versus isCGM.

METHODS

In this crossover trial, adults with type 1 diabetes were randomized to use isCGM or DIY-rtCGM for eight weeks before crossover to use the other device for eight weeks, after a four-week washout period where participants reverted back to isCGM. The primary endpoint was time in range (TIR; 3.9-10 mmol/L). Secondary endpoints included other glycemic control measures, psychosocial outcomes, and sleep quality.

RESULTS

Sixty participants were recruited, and 52 (87%) completed follow-up. Glucose outcomes were similar in the DIY-rtCGM and isCGM groups, including TIR (53.1% vs 51.3%; mean difference -1.7% P = .593), glycosylated hemoglobin (57.0 ± 17.8 vs 61.4 ± 12.2 mmol/L; P = .593), and time in hypoglycemia <3.9 mmol/L (3.9 ± 3.8% vs 3.8 ± 4.0%; P = .947). Hypoglycemia Fear Survey total score (1.17 ± 0.52 vs 0.97 ± 0.54; P = .02) and fear of hypoglycemia score (1.18 ± 0.64 vs 0.97 ± 0.45; P = .02) were significantly higher during DIY-rtCGM versus isCGM. Diabetes Treatment Satisfaction Questionnaire status (DTSQS) score was also higher with DIY-rtCGM versus isCGM (28.7 ± 5.8 vs 26.0 ± 5.8; P = .04), whereas diabetes-related quality of life was slightly lower (DAWN2 Impact of Diabetes score: 3.11 ± 0.4 vs 3.32 ± 0.51; P = .045); sleep quality did not differ between the two groups.

CONCLUSION

Although the use of DIY-rtCGM did not improve glycemic outcomes compared with isCGM, it positively impacted several patient-reported psychosocial variables. DIY-rtCGM potentially provides an alternative, cost-effective rtCGM option.

Cardiovascular and Renal Biomarkers in Overweight and Obese Adults with Type 1 Diabetes Treated with Tirzepatide for 21 Months

Introduction: Overweight (OW) and obesity (OB) affect nearly two thirds of adults with type 1 diabetes (T1D), contributing to suboptimal glucose control, cardiovascular disease (CVD), and diabetic kidney disease (DKD). Many newer drugs such as tirzepatide (a dual-incretin) and sodium-glucose cotransporter-2 inhibitors are approved for people with type 2 diabetes associated with CVD and DKD. We evaluated CVD and DKD biomarkers with off-label long-term (21 months) use of tirzepatide in OW/OB adults with T1D. Materials and Methods: In this retrospective chart review study, we analyzed data for 84 OW/OB adults with T1D who were prescribed tirzepatide since July 2022 and had used tirzepatide for at least 6 months. Controls (n = 38) were frequency matched for age, diabetes duration, sex, glycosylated hemoglobin (HbA1c), and body mass index (BMI). Data were collected from electronic medical records before initiating tirzepatide and over 21 months of treatment. Linear mixed effects models were used to examine the changes in lipids, blood pressure, and estimated glomerular filtration rate (eGFR) over time in tirzepatide-treated adults versus controls. Results: Baseline characteristics were similar except that tirzepatide users had a slightly higher baseline BMI than controls; 35.2 ± 4.8 kg/m2 and 33.3 ± 4.2 kg/m2 (P = 0.03), respectively. Patients using tirzepatide lost significantly more weight (-59 ± 4.6 lbs [-23.4%]) compared with a gain of (+1.7 ± 5.0 lbs [+1.8%]) in controls over 21 months. The HbA1c decreased more in patients using tirzepatide than controls (-0.50 ± 0.07% and -0.24 ± 0.09%, respectively, P = 0.017). Patients using tirzepatide significantly improved total and low-density lipoprotein cholesterol, triglycerides, systolic blood pressure, and eGFR; these changes remained significant even after adjusting for weight and HbA1c. The eGFR declined significantly in controls but not in the tirzepatide users. Conclusions: We conclude that long-term use of tirzepatide in OW/OB adults with T1D results in more than 23% weight loss and sustained improvement in glucose control. Irrespective of changes in weight and/or HbA1c, we observed significant improvement in cardiovascular biomarkers and preservation of kidney function. We strongly recommend a long-term randomized control trial with tirzepatide in patients with T1D.