ISPAD Clinical Practice Consensus Guidelines 2022: Diabetes in adolescence

Improved self-management of type 1 diabetes in young women: Experiences of Guided Self-Determination-Young: A qualitative interview study

AIMS

Young women with type 1 diabetes (T1D) have higher risks of diabetes complications and report higher diabetes distress and lower quality of life than men with T1D. Their experiences of self-management and need for support have received little attention, and targeted interventions are lacking. The aim of this qualitative interview study was to explore the experiences of young women with T1D after participating in an intervention with the person-centred reflection and problem-solving model Guided Self-Determination-Young (GSD-Y), with a focus on self-management and support in daily diabetes care.

METHODS

A qualitative interview study was performed in a paediatric and an adult diabetes outpatient clinic in Sweden. After participating in an intervention with GSD-Y, 12 women (15-20 years) with T1D were selected and interviewed individually. The interviews were analysed using inductive qualitative content analysis.

RESULTS

The analysis revealed an overarching theme: 'A person-centred approach facilitated deeper reflection on both an individual and a relational level', and two main categories: 'The process initiated within the individual', and 'The process initiated together with the health care provider'. The women experienced increased knowledge of, and increased ability to manage diabetes. They also experienced a new type of relationship with the health care provider, including exchange of in-depth information beyond glucose levels, which appeared to increase their ability to receive support.

CONCLUSIONS

The GSD-Y model provided tools to explore and clarify the individual needs of young women with T1D, which supported diabetes self-management. Person-centred care was enabled when the women became engaged as active partners in diabetes health care.

The transfer of care experience in young adults with type 1 diabetes

OBJECTIVES

To explore the experiences and perceptions of young adults with type 1 diabetes (T1D) after they transferred care from a pediatric to an adult clinic, utilizing an organized transfer process that included a Diabetes Transition Clinic (DTC) and a transfer letter (TL).

METHODS

This retrospective study used a semi-structured interview 1-1.5 years after transfer of care, which gathered both quantitative and qualitative data of young adults (n=12) who transferred care at an average age of 19.6 years, within a Midwest academic medical center. Descriptive statistics and thematic analysis were used to analyze the data and to identify emerging themes.

RESULTS

Most participants were worried about their transfer of care and found attending a DTC valuable. Most found the TL helpful in summarizing their diabetes care. Emerging themes demonstrated the importance of preparing the young adult for change, supporting their emotional journey, and developing connections with their new diabetes team.

CONCLUSIONS

For young adults with diabetes, the transfer of care from pediatric to adult is a time of apprehension. Incorporating a DTC and TL can facilitate this journey by preparing patients for change and developing ways to deepen connections with new providers.

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.

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.

Impact of Covid-19 on children and adolescents with type 1 diabetes: lifestyle, telecommunication service, and quality of life

OBJECTIVES

The COVID-19 pandemic brought about major changes, such as lifestyle changes, modification in telecommunication, as well as increased mental and psychological burden. This has raised concerns regarding its impact on the quality of life of children and adolescents with type 1 diabetes. To detect the impact of COVID-19 pandemic on children and adolescents with type 1 diabetes in terms of lifestyle changes and telecommunication service using a predesigned questionnaire, as well as quality of life using the Pediatric Quality of Life Inventory (PedsQL).

METHODS

A cross-sectional study including 286 participants with type 1 diabetes at the Pediatrics and Adolescent Diabetes Unit was conducted from March to August 2022. A predesigned questionnaire was used to collect data about lifestyle, telecommunication service, and quality of life using PedsQL.

RESULTS

Results show that most of the participants (62.2 %) food consumption increased during the lockdown period. Moreover, results also reveal that 79.7 % of the participants were informed about the telecommunication service, 93.4 % of them actually used it, and 88.6 % thought it was simple. As regards the quality of life, there was a statistically significant difference in PedsQL total score between the younger and older groups, with a p-value=0.009 indicating a better quality of life in the older group.

CONCLUSIONS

The COVID-19 pandemic influenced the lifestyle of children and adolescents with type 1 diabetes. Their food consumption increased, the telemedicine service was easy to use and appealed to the majority, and the quality of life of older participants was better.

A Multidisciplinary Approach of Type 1 Diabetes: The Intersection of Technology, Immunotherapy, and Personalized Medicine

Background: Type 1 diabetes (T1D) is a chronic autoimmune disorder characterized by the destruction of pancreatic β-cells, leading to absolute insulin deficiency. Despite advancements in insulin therapy and glucose monitoring, achieving optimal glycemic control remains a challenge. Emerging technologies and novel therapeutic strategies are transforming the landscape of T1D management, offering new opportunities for improved outcomes. Methods: This review synthesizes recent advancements in T1D treatment, focusing on innovations in continuous glucose monitoring (CGM), automated insulin delivery systems, smart insulin formulations, telemedicine, and artificial intelligence (AI). Additionally, we explore biomedical approaches such as stem cell therapy, gene editing, immunotherapy, gut microbiota modulation, nanomedicine-based interventions, and trace element-based therapies. Results: Advances in digital health, including CGM integration with hybrid closed-loop insulin pumps and AI-driven predictive analytics, have significantly improved real-time glucose management. AI and telemedicine have enhanced personalized diabetes care and patient engagement. Furthermore, regenerative medicine strategies, including β-cell replacement, CRISPR-based gene editing, and immunomodulatory therapies, hold potential for disease modification. Probiotics and microbiome-targeted therapies have demonstrated promising effects in maintaining metabolic homeostasis, while nanomedicine-based trace elements provide additional strategies to regulate insulin sensitivity and oxidative stress. Conclusions: The future of T1D management is shifting toward precision medicine and integrated technological solutions. While these advancements present promising therapeutic avenues, challenges such as long-term efficacy, safety, accessibility, and clinical validation must be addressed. A multidisciplinary approach, combining biomedical research, artificial intelligence, and nanotechnology, will be essential to translate these innovations into clinical practice, ultimately improving the quality of life for individuals with T1D.

Dynamic assessment of a transition process for patients with diabetes

Introduction

Adolescence can be defined as the period during which all individuals move from childhood to adulthood, including in the healthcare system, creating a need for a healthcare transition process. Children's of Alabama provides four transition education sessions during clinic visits for adolescents with type 1 diabetes (T1D). We aimed to assess baseline patient data and patient perspectives of our current transition education process to guide our efforts to improve this process.

Methods

We used a mixed methods design comprised of a quantitative analysis of baseline data in our adolescents with T1D and qualitative analysis of provide and patient perspectives. We queried the electronic medical record to obtain baseline characteristics of adolescent adolescents with T1D seen at our center from January 2022 to May 2022 and sought input via anonymous surveys of adult and pediatric endocrinology attendings, fellows, and nurse practitioners at our institution and of adolescents with T1D who had completed the final education session via an electronic secure database.

Results

Electronic Medical review of adolescents with T1D transitioning to adult care at our center revealed most of our adolescents with T1D had a gap in care of four months or greater between last pediatric visit and first adult visit. Pediatric provider surveys emphasized barriers for adolescents with T1D with appointment scheduling and challenges navigating the adult health care system. Adult surveys emphasized lack of communication with the adult health care team. Adolescents with T1D overall reported transition education prepared them well for adult care, but only 35.3 % had identified an adult provider after completing transition education.

Conclusions

Our findings outline additional areas for improvement in our transition process for adolescents with T1D. Based on feedback from the pediatric team, we are working to initiate transition education by age 16, standardize document discussions around transition, document date of planned transition, and document planned accepting adult provider. We are working to streamline record transfer based on feedback from adult providers. Based on patient feedback and our documented gaps in care, we are working to place referrals for adult care to minimize gaps in diabetes care.

Parental perspectives following the implementation of advanced hybrid closed-loop therapy in children and adolescents with type 1 diabetes and elevated glycaemia

AIMS

To identify from a parental perspective facilitators and barriers of effective implementation of advanced hybrid closed-loop (AHCL) therapy in children and adolescents with type 1 diabetes (T1D) with elevated glycaemia.

METHODS

Semi-structured interviews were conducted with parents of participants while in a post-trial extension phase of the CO-PILOT randomized controlled trial. The Capability, Opportunity, Motivation, Behaviour Model and Theoretical Domain Framework informed the interviews and framework analysis.

RESULTS

Eleven parents of 9 children and adolescents were interviewed. The median age of their children and adolescents was 14.2 years (IQR 13.3-14.7) with median HbA1c 78 mmol/mol (IQR 75-86) (9.3% IQR 9-10) before starting AHCL. Facilitators of implementing AHCL therapy included the following: (1) knowledge acquired from training, (2) establishing routines and action plans, (3) remote glucose monitoring, (4) achievement of glycaemic goals through automation, (5) children/adolescents' capability to use AHCL independently, (6) improved outcomes incentivized continued AHCL, (7) optimism about sustained improvements and (8) social support from healthcare providers, school staff, peers and parents. Barriers to AHCL implementation included the following: (1) challenges with device usability, (2) need for technical support, (3) forgotten knowledge and skills, (4) non-adherence to best practices, (5) negative social influences, (6) physical and psychosocial burden and (7) negative emotions.

CONCLUSIONS

This study provides comprehensive insights into parental perspectives of influences on implementing AHCL therapy in children and adolescents with elevated glycaemia. As parents remain key partners in diabetes care, these findings inform successful implementation of AHCL and development of future diabetes technology.

Time in tight glucose range in adolescents and young adults with diabetes during Ramadan intermittent fasting: Data from real-world users on different treatment strategies

BACKGROUND

Time in tight range (TITR) is a novel glycemic metric assessing normoglycemia in individuals with diabetes.

AIM

To assess the attainability of the TITR (70-140 mg/dL) target in youth with diabetes using different treatment strategies during Ramadan fasting.

METHODS

This prospective study included 276 non-insulin-treated type 2 diabetes mellitus (T2DM) and 426 patients with type 1 diabetes mellitus (T1DM) who were categorized into: multiple daily injections [MDI] + intermittently scanned CGM (isCGM), sensor augmented pump (SAP) and advanced hybrid closed loop (AHCL).

RESULTS

At the end of Ramadan, the mean TITR was 42.3 ± 6.6 % for all T1DM patients and 63.5 ± 4.0 % in T2DM (p < 0.001). The highest TITR was in T2DM group together with T1DM on AHCL (62.3 ± 11.6 %), followed by SAP group (37.7 ± 5.7 %) and MDI + isCGM group (23.6 ± 5.9 %, p < 0.001). Hypoglycemic episodes as shown by time below range (TBR) < 70 mg/dL and TBR < 54 mg/dL were minimal during Ramadan in AHCL group in comparison to before Ramadan (2.6 ± 0.7 versus 2.9 ± 0.9 %; p = 0.061 and 0.4 ± 0.1 vs 0.5 ± 0.1 %, p = 0.561, respectively) with a lower coefficient of variation (CoV) (p < 0.001) than other T1DM participants.

CONCLUSION

At the end of Ramadan, TITR was decreased in patients with T1DM except those using AHCL who had similar levels to non-insulin-treated T2DM patients. Advanced technology has the potential for achieving tight glycemic targets, along with a reduction in CoV, without increasing hypoglycemic risk compared with other insulin treatment modalities.

An audit and feedback-based intervention to improve diabetes management in the year after transfer to adult type 1 diabetes care: A multi-center quasi-experimental study

AIM

To test whether an audit and feedback-based intervention improved HbA1c 12 months after transfer to type 1 diabetes adult care.

METHODS

Multi-centre, quasi-experimental pre-post study of an AF-based intervention targeting paediatric diabetes teams, which encouraged the implementation of an evidence-informed structured transition process at five paediatric diabetes centres in Ontario, Canada. Participants entered the study at their final paediatric visit. A parallel control cohort was ascertained using population-based administrative datasets. The primary outcome was HbA1c 12 months after transfer. The main exposure was the study period: pre-implementation (June 2018-May 2019); early-implementation (June 2019-September 2020); and late-implementation (October 2020-September 2021). Multivariable linear regression models were fit separately in each cohort.

RESULTS

There were 449 and 2844 individuals in the intervention and control cohorts, respectively. Twelve months after transfer, participants in the late-implementation intervention cohort had an HbA1c that was, on average, 0.41% lower than participants in the pre-implementation period (p = 0.016). Among the control cohort, there was no significant difference in the HbA1c 12 months after transfer between study periods.

CONCLUSIONS

We found an effect of the intervention on glycaemic management one year following transfer to adult care. Future work will focus on refining and testing the effectiveness of the intervention in an expanded number of study sites and in collaboration with adult diabetes care providers.

Characteristics of Children, Youth, and Young Adults With Diabetes: A Cross-Sectional Study in New Zealand Aotearoa

Background: The prevalence of diabetes mellitus among children, youth, and young adults is increasing, yet limited information is known about the characteristics and management of these groups with Type 1 (T1D) and Type 2 (T2D) diabetes in primary care. The aim of the study is to explore the characteristics of people with T1D and T2D aged < 25 years across the Auckland and Waikato regions of New Zealand. Methods: Sociodemographic and clinical data were collected from electronic primary care records (February 2021-July 2022) of four primary healthcare organisations, with medication data sourced from the National Pharmaceutical dataset. Associations between sociodemographic and clinical data were conducted using chi-square and nonparametric ANOVA. Results: Of 1198 patients, 72% had T1D and 28% had T2D. People with T1D were evenly distributed by gender but more commonly of European descent (66.7%) compared to other ethnic groups. A higher proportion of T2D was observed in females (58.2%) compared to males (41.6%) and among Māori (38.2% vs. 20.3% European; p < 0.001). Over 95% of individuals with T2D were overweight/obese. Overall, 9.5% and 23.9% of individuals with T1D and T2D, respectively, were at target for HbA1c, though median HbA1c was higher for Māori and Pasifika compared to other ethnicities (p < 0.001). In T1D, 94.7% of individuals were dispensed insulin and 7.5% and 4.4% were dispensed angiotensin-converting enzyme (ACE) inhibitors and statins, respectively. In T2D, medication use included metformin (84.9%), insulin (76.1%), and SGLT2i/GLP1RA (59.5%). Conclusions: The increasing burden of diabetes among young individuals in New Zealand underscores the urgent need for comprehensive strategies to address obesity and socioeconomic disparities, especially among marginalised communities. Addressing socioeconomic factors such as affordable housing, living wages, and healthcare access may be important for improving diabetes outcomes, as these factors significantly influence overall childhood health and well-being.

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

INTRODUCTION

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Improved Glycemic Control during a One-Week Adventure Camp in Adolescents with Type 1 Diabetes-The DIACAMP Study

Adolescence remains a crucial age associated with diabetes distress in individuals living with type 1 diabetes (T1D). The Austrian organization "Diabär" regularly hosts a one-week adventure camp for adolescents (12-18 years) living with T1D. The camp focuses on "fun activities" without a structured educational protocol in order to minimize diabetes distress and increase diabetes management skills. In contrast to educational camps, training is kept to a minimum. However, attendees analyze the glycemic data of the previous day with their medical supervisor once daily during the camp. All subjects used a standardized real-time continuous glucose monitoring (CGM) system (DexcomG7) throughout the whole study. Glycemic metrics were prospectively analyzed during three periods: week 1 = home phase, week 2 = adventure camp, and week 3 = after the camp. Safety (time below range 1 [TBR1], 69-54 mg/dL, and time below range 2 [TBR2], <54 mg/dL) and efficacy (time in range [TIR], 70-180 mg/dL) were assessed by comparing the CGM data during weeks 1-3. The CGM data of 14 participants were analyzed. The TIR was higher during the camp week versus week 1 (70.4 ± 11.1% vs. 53.1 ± 20.2%; p = 0.001). The TBR1 significantly increased during camp compared to week 1 (2.5 ±1.7% vs. 1.3 ± 1.2%; p = 0.009), whereas the TBR2 did not differ. No serious adverse events occurred. This adventure camp without a main focus on education showed feasibility and safety in adolescents with T1D.

Psychological and Clinical Challenges in the Management of Type 1 Diabetes during Adolescence: A Narrative Review

Adolescence, a critical period of physical and psychological development, presents unique challenges in type 1 diabetes (T1D) management due to endocrinological changes, reduced therapeutic adherence, and elevated susceptibility to psychological issues such as depression, anxiety, and eating disorders. This narrative review explores the impact of psychological and behavioral factors on glycemic control in adolescents with T1D. We examine the prevalence and influence of mental health disorders, lifestyle factors, harmful behaviors, and social dynamics on diabetes management and glycemic outcomes. Strategies for improving metabolic control are also reviewed, including cognitive behavioral therapy, technological devices, and educational interventions. The importance of tailored psychological support, family involvement, and targeted interventions to improve adherence to treatment and glycemic control in adolescents with T1D should be emphasized.

Developing Self-Management in Type 1 Diabetes at Secondary Schools: Who Is Responsible? A Qualitative Study

IMPORTANCE

Occupational therapists have the proven capacity to improve outcomes for young adults who are self-managing Type 1 diabetes (T1D). There is insufficient understanding of adolescents' experiences of developing responsibility for diabetes self-management (DSM).

OBJECTIVE

To investigate adolescents' perceptions of sharing responsibility for T1D management at school.

DESIGN

This study had a descriptive qualitative design and used semistructured interviews and thematic analysis. It is the second phase of a mixed-methods study with a sequential explanatory design that investigated mechanisms of responsibility-sharing at school.

SETTING

Secondary school in Australia.

PARTICIPANTS

Purposive sample of adolescents (age 15-16 yr) with T1D (N = 11).

RESULTS

Adolescents approached the complex occupation of school-based DSM primarily in partnership with their parents, with each adolescent having unique responsibilities while sharing others. Health care professionals and teachers reportedly had minimal involvement. Adolescents described owning most DSM tasks, with their perceptions of building independence limiting the sharing of this responsibility. A heightened sense of risk meant that adolescents were likely to communicate with others in cases of errant blood glucose readings. Current processes commonly resulted in reduced school participation.

CONCLUSIONS AND RELEVANCE

Adolescents valued working responsively and interdependently with their parents to manage T1D at school, which aligns with the occupational therapy model of co-occupation. Effective responsibility-sharing depends on clear, frequent, autonomy-supportive, team-based communications. Our results showed that patterns of communication for determining school-based DSM processes were fragmented and risk focused, with limited adolescent involvement, resulting in strategies that led to students at times being excluded from school activities. Plain-Language Summary: This is the first study to use an occupational lens to examine the way in which adolescents share their responsibility for diabetes care at school. Diabetes self-management in secondary schools occurs more often when adolescents work interdependently with their parents to manage their diabetes. Adolescent involvement in formal school processes and a clearer allocation of team roles and responsibilities would better support health-promoting habits and school participation.

Peer support in adolescents and young adults with chronic or rare conditions in northern America and Europe: Targeted literature review

PROBLEM

Adolescents and young adults with chronic or rare conditions face unique risks to their physical, social and emotional development. Research suggests that peer support improves their quality of life and reduces social isolation. However, there is a paucity of current information considering multiple intervention formats.

ELIGIBILITY CRITERIA

A targeted literature review was conducted to identify peer support interventions and assess their feasibility, acceptability and efficacy for this population. Searches were conducted in MEDLINE, Embase and American Psychological Association PsycINFO for records reporting peer support interventions in young adults with chronic or rare conditions. Data were extracted from relevant publications and qualitatively evaluated.

SAMPLE

Thirty studies were included, which assessed the use of peer support for young adults (aged 13-30 years) with chronic or rare conditions in Europe or North America.

RESULTS

Peer support interventions had positive effects on social positivity, psychosocial development and medical outcomes, though significance was not always demonstrated.

CONCLUSIONS

Peer support can enhance care for young adults with chronic or rare conditions. Current literature suggests that once-weekly virtual interventions are the most feasible and acceptable for patients, leading to multifaceted improvements in their well-being.

IMPLICATIONS

This study is one of the first to discuss in-person, virtual and hybrid peer-based interventions for young adults with chronic and rare conditions. While all formats improved social, psychological and medical outcomes, virtual formats may be most accessible to participants. Interventions should be made available to this population, and guidelines for optimal implementation of peer support are needed.

Sustained 3-Year Improvement of Glucose Control With Hybrid Closed Loop in Children With Type 1 Diabetes While Going Through Puberty

OBJECTIVE

To evaluate the impact of prolonged hybrid closed loop (HCL) use in children with type 1 diabetes (T1D) on glucose control and BMI throughout pubertal progression.

RESEARCH DESIGN AND METHODS

We used a prospective multicenter extension study following the Free-Life Kid AP (FLKAP) HCL trial. The 9-month previously reported FLKAP trial included 119 prepubertal children (aged 6-12 years). During the extension study, participants could continue to use HCL for 30 months (M9 to M39). HbA1c values were collected every 3 months up to M39, while continuous glucose monitoring metrics, BMI z scores, and Tanner stages were collected up to M24. Noninferiority tests were performed to assess parameter sustainability over time.

RESULTS

One hundred seventeen children completed the extension study, with mean age 10.1 years (minimum to maximum, 6.8-14.0) at the beginning. Improvement of HbA1c obtained in the FLKAP trial was significantly sustained during extension (median [interquartile range], M9 7.0% [6.8-7.4], and M39 7.0% [6.6-7.4], P < 0.0001 for noninferiority test) and did not differ between children who entered puberty at M24 (Tanner stage ≥2; 54% of the patients) and patients who remained prepubertal. BMI z score also remained stable (M9 0.41 [-0.29 to 1.13] and M24 0.48 [-0.11 to 1.13], P < 0.0001, for noninferiority test). No severe hypoglycemia and one ketoacidosis episode not related to the HCL system occurred.

CONCLUSIONS

Prolonged use of HCL can safely and effectively mitigate impairment of glucose control usually associated with pubertal progression without impact on BMI in children with T1D.

Mental disorders in children and adolescents with type 1 diabetes before and during the COVID-19 pandemic: results from the DPV registry

OBJECTIVES

The COVID-19 pandemic affected the mental health of children and adolescents in the general population, yet its impact on those with chronic conditions is relatively unknown. This study aimed to compare the incidences of comorbid mental disorders and substance misuse in children and adolescents with type 1 diabetes before and during the pandemic.

METHODS

A total of 42,975 patients aged 6-18 years from the multicentre DPV (Diabetes Prospective Follow-up) registry were included. Multivariable regression models were applied to compare newly diagnosed comorbid mental disorders, adjusted for demographic and clinical variables, among them the number of medical visits, during the pre-pandemic period (09/2017-02/2020) and the COVID-19 pandemic period (03/2020-08/2022).

RESULTS

Analysing both sexes together, there were no differences in the incidence rates of overall mental disorders between the pandemic and the pre-pandemic period. However, girls showed an increased incidence rate (odds ratio 1.2, CI 1.1-1.3) during the pandemic. Adolescent girls also displayed higher incidence rates of depression, eating disorders, and self-harm. Substance misuse declined overall during the pandemic (odds ratio 0.8, CI 0.7-0.9).

CONCLUSIONS

During the COVID-19 pandemic, we found higher incidence rates of overall mental disorders in girls, but not in boys and not in the total study population of children and adolescents with type 1 diabetes. Adolescent girls displayed increased incidence rates of depression, eating disorders, and self-harm. Substance misuse declined substantially. Clinicians should be aware of the high-risk group of adolescent girls during times of increased strain.

Telemedicine in Improving Glycemic Control Among Children and Adolescents With Type 1 Diabetes Mellitus: Systematic Review and Meta-Analysis

BACKGROUND

Type 1 diabetes mellitus (T1DM) is the most common chronic autoimmune disease among children and adolescents. Telemedicine has been widely used in the field of chronic disease management and can benefit patients with T1DM. However, existing studies lack high-level evidence related to the effectiveness of telemedicine for glycemic control in children and adolescents with T1DM.

OBJECTIVE

This study aims to systematically review the evidence on the effectiveness of telemedicine interventions compared with usual care on glycemic control among children and adolescents with T1DM.

METHODS

In this systematic review and meta-analysis, we searched PubMed, Cochrane Library, Embase, Web of Science (all databases), and CINAHL Complete from database inception to May 2023. We included randomized controlled trials (RCTs) that evaluated the effectiveness of a telemedicine intervention on glycemic control in children and adolescents with T1DM. In total, 2 independent reviewers performed the study selection and data extraction. Study quality was assessed using the Cochrane Risk of Bias 2 tool. Our primary outcome was glycated hemoglobin (HbA1c) levels. Secondary outcomes were quality of life, self-monitoring of blood glucose, the incidence of hypoglycemia, and cost-effectiveness. A random-effects model was used for this meta-analysis.

RESULTS

Overall, 20 RCTs (1704 participants from 12 countries) were included in the meta-analysis. Only 5% (1/20) of the studies were at high risk of bias. Compared to usual care, telemedicine was found to reduce HbA1c levels by 0.22 (95% CI -0.33 to -0.10; P<.001; I2=35%). There was an improvement in self-monitoring of blood glucose (mean difference [MD] 0.54, 95% CI -0.72 to 1.80; P=.40; I2=67.8%) and the incidence of hypoglycemia (MD -0.15, 95% CI -0.57 to 0.27; P=.49; I2=70.7%), although this was not statistically significant. Moreover, telemedicine had no convincing effect on the Diabetes Quality of Life for Youth score (impact of diabetes: P=.59; worries about diabetes: P=.71; satisfaction with diabetes: P=.68), but there was a statistically significant improvement in non-youth-specific quality of life (MD -0.24, 95% CI -0.45 to -0.02; P=.04; I2=0%). Subgroup analyses revealed that the effect of telemedicine on HbA1c levels appeared to be greater in studies involving children (MD -0.41, 95% CI -0.62 to -0.20; P<.001), studies that lasted <6 months (MD -0.32, 95% CI -0.48 to -0.17; P<.001), studies where providers used smartphone apps to communicate with patients (MD -0.37, 95% CI -0.53 to -0.21; P<.001), and studies with medication dose adjustment (MD -0.25, 95% CI -0.37 to -0.12; P<.001).

CONCLUSIONS

Telemedicine can reduce HbA1c levels and improve quality of life in children and adolescents with T1DM. Telemedicine should be regarded as a useful supplement to usual care to control HbA1c levels and a potentially cost-effective mode. Meanwhile, researchers should develop higher-quality RCTs using large samples that focus on hard clinical outcomes, cost-effectiveness, and quality of life.

Digital interventions for adolescents with type 1 diabetes to promote health literacy? A qualitative study on physicians' perspective in Germany

Introduction

Adolescents with type 1 diabetes mellitus (T1D) require a high level of health literacy (HL) to prevent complications. It remains unclear what potential digital interventions have for promoting HL among adolescents with T1D, as viewed by physicians working with this target group. Additionally, it is unclear how the institutions (inpatient care and outpatient care) can support and facilitate the use of digital interventions to promote HL.

Research design and methods

An exploratory study was conducted using semistructured interviews with physicians (n=12) in Germany. The interview questions are based on a previous systematic review. The coding was conducted deductively and inductively using MAXQDA software. Subsequently, the interviews were analysed systematically through an iterative process of content analyses in line with Kuckartz et al.

Results

It was reported by the physicians that digital interventions are underused due to technical resources, lack of structural conditions, information and legal constraints. The utilisation of digital interventions to promote HL was heterogeneous and depended primarily on the willingness of the physicians. Communication strategy techniques were widely employed to motivate patients, an activity occurring mainly in-person, thus limiting the opportunity for the deployment of digital interventions.

Conclusions

To increase the use of digital interventions and improve HL, support for digital literacy skills could be implemented. Capacity building through patient-centred, interdisciplinary and participatory culture should be considered. The findings of this study can provide valuable insights for practice, research and policy.

Observed collaborative and intrusive parenting behaviours associated with psychosocial outcomes of adolescents with type 1 diabetes and their maternal caregivers

AIMS

Maternal caregiver involvement is strongly associated with psychosocial and glycemic outcomes amongst adolescents with type 1 diabetes (T1D); however, previous studies have lacked detailed, objective examinations of caregiver involvement. We examined the relationship between observed parenting behaviors and psychosocial and glycemic outcomes amongst youth with T1D.

METHODS

Data collected from adolescents with T1D (age 11-17) and their female caregivers as a part of a randomized controlled trial were analyzed. These included structured, observation-based scores of adolescent-caregiver dyads engaged in videotaped interactions and selected psychosocial and glycemic outcome measures.

RESULTS

In adjusted analyses, higher levels of intrusive parenting behaviors during observed interactions were associated with higher diabetes distress in adolescents, but no difference in HbA1c. Associations between intrusive parenting behaviors and psychosocial outcomes were stronger for females compared to males for both diabetes distress and quality of life. Similarly, associations between collaborative parenting behaviors and quality of life were stronger for female adolescents than males. No associations were observed between collaborative parenting behaviors and glycemic outcomes. Consistent with previous work, we noted higher levels of adolescent-reported family conflict were associated with lower adolescent quality of life and higher diabetes distress with no significant difference between male and female adolescents.

CONCLUSION

These findings indicate that high levels of intrusive parenting behaviors, such as lecturing or over-controlling behaviors, are associated with lower levels of adolescent well-being, particularly among adolescent girls. This work suggests that interventions to reduce intrusive parenting by maternal caregivers could result in improved psychosocial outcomes for adolescents with T1D.

Delayed menarche in children and adolescents with type 1 diabetes mellitus: a systematic review and meta-analysis

Several studies have reported an association between age at menarche and the onset of type-1 diabetes mellitus (T1DM). This review compared the age at menarche in patients who had menarche after T1DM diagnosis with that of patients who were healthy and/or had menarche before T1DM diagnosis. Searches were conducted using four databases. The outcome was the age at menarche of patients who had menarche after T1DM diagnosis and patients who were healthy and/or had menarche before T1DM diagnosis. A qualitative analysis was performed using the JBI (Joanna Briggs Institute) Critical Appraisal. Quantitative analysis of the mean differences was performed using Revman 5.4 tool. A total of 1952 studies were obtained from the initial search. The final results were 13 articles that met the inclusion criteria for the qualitative assessment and eight for the quantitative assessment. Eight studies included 1030 patients who had menarche after being diagnosed with T1DM and 1282 patients who were healthy and/or had menarche before T1DM diagnosis. The meta-analysis showed a cumulative effect on a mean difference of 0.87 (95% CI: 0.75; 0.99, p-value < 0.00001), indicating a later age at menarche in patients who had menarche after T1DM diagnosis. The age at menarche was later in patients who had menarche after T1DM diagnosis compared to healthy subjects and those who had menarche beforehand.

Using person reported outcomes: Psychometric properties of the German diabetes treatment satisfaction questionnaire (DTSQ) for teens and parents

Aims

To examine psychometric properties including the factor structure of the German versions of the Diabetes Treatment Satisfaction Questionnaire for teens and parents (DTSQ-T/-P).

Methods

Linguistically validated questionnaires were completed by 363 adolescents with type 1 diabetes and 655 parent-caregivers in a multicenter study. Confirmatory factor analysis (CFA), reliability, and correlations were examined.

Results

CFA confirmed the 2-factor model of treatment satisfaction (TS) & perceived diabetes control (PDC) with an adjustment of removing the "medical support" item from the TS and examining it as a single item in this study. Cronbach's α of TS for DTSQ-T/-P was 0.82 & 0.83, respectively, and α of the two-item PDC factor was 0.70 & 0.60, respectively. The DTSQ scale scores positively correlated with time in range and inversely correlated with HbA1c. Scale scores of DTSQ-T/-P showed significantly positive relations to the KIDSCREEN-10 Index and negative associations with the Problem Areas in Diabetes (PAID). The TS of the parents was correlated with depressive symptoms measured in the Patient Health Questionnaire-9.

Conclusions

The DTSQ-T/-P produced psychometrically sound scores in measuring diabetes treatment satisfaction in German teens with type 1 diabetes and their parents. German DTSQ versions for teens and parents are recommended in research and clinical practice.

Aiming for the Best Glycemic Control Beyond Time in Range: Time in Tight Range as a New Continuous Glucose Monitoring Metric in Children and Adolescents with Type 1 Diabetes Using Different Treatment Modalities

Introduction: To evaluate time in tight range (TITR) 70-140 mg/dL (3.9-7.8 mmol/L), its correlation with standard continuous glucose monitoring (CGM) metrics and the clinical variables that possibly have a substantial impact on its value, in a large cohort of pediatric subjects using different treatment strategies. Materials and Methods: A total of 854 children and adolescents with type 1 diabetes were consecutively recruited in this real world, dual center, cross-sectional study. Participants were categorized into four treatment groups (multiple daily injections [MDI] + real-time CGM, MDI + intermittently scanned CGM, sensor augmented pump, and hybrid closed loop [HCL]). Demographical and clinical data, including CGM data, were collected and analyzed. Results: The overall study population exhibited an average TITR of 36.4% ± 12.8%. HCL users showed higher TITR levels compared to the other treatment groups (P < 0.001). A time in range (TIR) cut-off value of 71.9% identified subjects achieving a TITR ≥50% (area under curve [AUC] 0.98; 95% confidence interval 0.97-0.99, P < 0.001), and a strong positive correlation between these two metrics was observed (r = 0.95, P < 0.001). An increase in TIR of 1% was associated with 1.84 (R2 Nagelkerke = 0.35, P < 0.001) increased likelihood of achieving TITR ≥50%. Use of HCL systems (B = 7.78; P < 0.001), disease duration (B = -0.26, P = 0.006), coefficient of variation (B = -0.30, P = 0.004), and glycated hemoglobin (B = -8.82; P < 0.001) emerged as significant predictors of TITR levels. Conclusions: Our study highlights that most children and adolescents with type 1 diabetes present TITR levels below 50%, except those using HCL. Tailored interventions and strategies should be implemented to increase TITR.

Psychosocial Care for Youth with Type 1 Diabetes: Summary of Reviews to Inform Clinical Practice

The intensive demands of diabetes care can be difficult for youth with type 1 diabetes and their families to integrate into daily life. Standards of care in pediatric diabetes highlight the importance of evidence-based psychosocial interventions to optimize self-management behaviors and psychological well-being. The current review summarizes select systematic reviews and meta-analyses on evidence-based behavioral health interventions in pediatric diabetes. Interventions include strategies to strengthen youth psychosocial skills, improve family dynamics and caregiver mental health, enhance health and mental health equity, and address psychosocial factors related to diabetes technology use.

The Burden of Type 1 and Type 2 Diabetes Among Adolescents and Young Adults in 24 Western European Countries, 1990-2019: Results From the Global Burden of Disease Study 2019

Objectives: As little is known about the burden of type 1 (T1DM) and type 2 diabetes (T2DM) in adolescents in Western Europe (WE), we aimed to explore their epidemiology among 10-24 year-olds. Methods: Estimates were retrieved from the Global Burden of Diseases Study (GBD) 2019. We reported counts, rates per 100,000 population, and percentage changes from 1990 to 2019 for prevalence, incidence and years lived with disability (YLDs) of T1DM and T2DM, and the burden of T2DM in YLDs attributable to high body mass index (HBMI), for 24 WE countries. Results: In 2019, prevalence and disability estimates were higher for T1DM than T2DM among 10-24 years old adolescents in WE. However, T2DM showed a greater increase in prevalence and disability than T1DM in the 30 years observation period in all WE countries. Prevalence increased with age, while only minor differences were observed between sexes. Conclusion: Our findings highlight the substantial burden posed by DM in WE among adolescents. Health system responses are needed for transition services, data collection systems, education, and obesity prevention.

Adolescents with type 1 diabetes' perspectives on digital health interventions to enhance health literacy: a qualitative study

Introduction

Digital health intervention offers the potential to enhance health literacy, which is crucial for effective diabetes management, especially among adolescents. Diabetes is a major global public health issue, leading to devastating complications and increasing mortality rates. The incidence of type 1 diabetes mellitus (T1DM) is also on the rise, particularly among adolescents, necessitating multisectoral strategies to combat this disease. This study explores the perceptions of adolescents with T1DM in Germany regarding digital health interventions, with the aim of improving healthcare by addressing specific needs and guiding future research.

Methodology

This study employed a qualitative approach using semi-structured individual interviews with adolescents with T1DM (n = 20) aged 14 to 18 years old in Germany to explore their perspectives on digital interventions for health literacy promotion. The study adopted content analysis according to Kuckartz et al. and the research followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. Ethical considerations were paramount and data were rigorously analyzed using coding and iterative processes to ensure data quality and reliability.

Results

The findings indicate that within three prominent domains, namely the utilization of digital health intervention for accessing and comprehending information, facilitating peer-to-peer interactions, and enhancing physician-patient communication and interaction, digital health interventions are either underutilized or insufficiently deployed. In addition, a notable observation is the apparent lack of patient-centered approaches for adolescents with T1DM in relation to digital health interventions and health literacy.

Conclusion

In order to enhance the utilization of digital health interventions and enhance health literacy it is essential to focus on capacity building through a patient-centered approach, to promote digital health literacy, and foster the cultivation of a participatory culture. The outcomes of this study offer valuable insights that can inform practical applications, further research endeavors, and influence policymaking.

Outcomes measured in studies assessing health systems interventions for type 1 diabetes management: A scoping review

AIMS

Describe the outcomes reported in research on health systems interventions for type 1 diabetes management in comparison to the outcomes proposed by a core outcome set (COS) for this condition, an essential list of outcomes that studies should measure.

METHODS

Systematic search of studies published between 2010 and 2021 reporting health systems interventions directed to improve the management of type 1 diabetes using PubMed, EMBASE and CENTRAL. Information on the outcomes was extracted and classified according to a COS: self-management, level of clinical engagement, perceived control over diabetes, diabetes-related quality of life, diabetes burden, diabetes ketoacidosis, severe hypoglycemia, and glycated hemoglobin (HbA1C).

RESULTS

187 studies were included. Most of the studies included either children (n = 82/187) or adults (n = 82/187) living with type 1 diabetes. The most common outcome measured was HbA1C (n = 149/187), followed by self-management (n = 105/187). While the least measured ones were diabetes ketoacidosis (n = 15/187), and clinical engagement (n = 0/187). None of the studies measured all the outcomes recommended in the COS. Additionally, different tools were found to be used in measuring the same outcome.

CONCLUSIONS

This study provides a description of what researchers are measuring when assessing health systems interventions to improve type 1 diabetes management. In contrast to a COS, it was found that there is a predominance of clinical-based outcomes over patient-reported outcome measures.

Mediterranean diet adherence and glycemic control in children and adolescents with type 1 diabetes

To effectively manage type 1 diabetes (T1D) insulin is essential, with dosages based on lifestyle. The Mediterranean diet has demonstrated its advantages in preventing and enhancing the management of chronic diseases. Our objective was to investigate the potential mediation of sensor activity on the relationship between adherence to the Mediterranean diet and glycemic control in children and adolescents. A total of 150 children and adolescents (mean age = 13.09, SD = 3.54; 44% female) with T1D were recruited. Adherence to the Mediterranean diet was assessed using the KIDMED questionnaire which evaluates 16 items and gives higher scores when adherence is higher. Glycemic control and the duration of sensor activity were evaluated with data from flash glucose monitoring. The data confirmed our hypothesis by revealing that adherence to the Mediterranean diet positively influenced glycemic control (direct effect = 1.505; P < 0.01) and that this relationship was mediated by the duration of sensor activity (indirect effect = 0.531; P < 0.01).  Conclusions: Our results support the increased utilization of glycemic control devices, as they contribute to improve glycemic control and mediate on the positive relationship between adherence to the Mediterranean diet and adequate glycemic control. Furthermore, our findings highlight the importance of incorporating Mediterranean diet recommendations to achieve better glycemic control in children and adolescents with T1D. What is Known: • The Mediterranean diet and glycemic control have proven benefits in improving cardiovascular health in the general population. Scarce evidence exists of these benefits among children and adolescents with T1D. What is New: • Adherence to the Mediterranean diet and greater use of glucose monitoring devices in children and adolescents with T1D are related to better glycemic control. These variables can be enhanced by psychoeducational interventions such as structured diabetes education programs or peer group-based sessions, which highlights the importance of focusing on these aspects.

Blood glucose forecasting from temporal and static information in children with T1D

Background

The overarching goal of blood glucose forecasting is to assist individuals with type 1 diabetes (T1D) in avoiding hyper- or hypoglycemic conditions. While deep learning approaches have shown promising results for blood glucose forecasting in adults with T1D, it is not known if these results generalize to children. Possible reasons are physical activity (PA), which is often unplanned in children, as well as age and development of a child, which both have an effect on the blood glucose level.

Materials and Methods

In this study, we collected time series measurements of glucose levels, carbohydrate intake, insulin-dosing and physical activity from children with T1D for one week in an ethics approved prospective observational study, which included daily physical activities. We investigate the performance of state-of-the-art deep learning methods for adult data-(dilated) recurrent neural networks and a transformer-on our dataset for short-term (30  min) and long-term (2  h) prediction. We propose to integrate static patient characteristics, such as age, gender, BMI, and percentage of basal insulin, to account for the heterogeneity of our study group.

Results

Integrating static patient characteristics (SPC) proves beneficial, especially for short-term prediction. LSTMs and GRUs with SPC perform best for a prediction horizon of 30  min (RMSE of 1.66  mmol/l), a vanilla RNN with SPC performs best across different prediction horizons, while the performance significantly decays for long-term prediction. For prediction during the night, the best method improves to an RMSE of 1.50  mmol/l. Overall, the results for our baselines and RNN models indicate that blood glucose forecasting for children conducting regular physical activity is more challenging than for previously studied adult data.

Conclusion

We find that integrating static data improves the performance of deep-learning architectures for blood glucose forecasting of children with T1D and achieves promising results for short-term prediction. Despite these improvements, additional clinical studies are warranted to extend forecasting to longer-term prediction horizons.

Experiences of transition to adulthood and transfer to adult care in young adults with type 1 diabetes: A qualitative study

AIM

To explore young adults' experiences of living with type 1 diabetes in the transition to adulthood, including experiences of the transfer from paediatric to adult care.

DESIGN

A qualitative approach was used.

METHOD

Ten young adults, six women and four men, aged 19-29 years, participated. Participants were recruited at their regular diabetes clinic from spring 2021 to spring 2022. Semi-structured interviews were transcribed and analysed using qualitative content analysis.

FINDINGS

Dreaming of being nurtured towards self-reliance was the overarching theme. Personal experiences of the transition to adulthood, including the transfer from paediatric to adult care, were described in terms of struggling to find balance in daily life, dealing with feelings of being different, being gradually supported to achieve independence, and wishing to be approached as a unique person in healthcare.

CONCLUSION

In healthcare, it is important to emphasize not only diabetes-related factors but also emotional and psychosocial aspects of life connected to the transition to adulthood, including the transfer to adult care. The young adults wished to be seen as unique persons in healthcare during their emerging adulthood and should therefore be supported to achieve self-reliance through personal preparations for new challenges and for the consequences of transitioning to adulthood. Specialist nurses can provide appropriate knowledge and leadership.

IMPLICATIONS FOR THE PROFESSION

These findings can guide nurse specialists in support for emerging adults to achieve self-reliance and indicate the importance of person-centred care when experiencing transition and transfer.

REPORTING METHOD

The study adhered to EQUATOR guidelines, and the COREQ checklist for qualitative studies was used as the reporting method.

Development and psychometric evaluation of TEXP-Q: a questionnaire measuring transition and transfer experiences in emerging adults with type 1 diabetes

BACKGROUND

During transition to adulthood and transfer to adult healthcare, emerging adults with chronic conditions are at risk of deteriorating disease control, well-being, and acute, as well as long-term complications. Despite an increasing call for person-centred healthcare services attuned to young peoples' needs, few validated instruments exist pinpointing adolescents' and emerging adults' experiences of preparation for transition and transfer. Thus, the overarching purpose of this study was to develop a person-centred, clinically applicable instrument (Transitional care EXPeriences Questionnaire, TEXP-Q) adjustable to different chronic conditions, although the focus in the present study was Type 1 Diabetes. The specific aim was, therefore, to describe the development and psychometric evaluation of TEXP-Q in emerging adults with Type 1 Diabetes.

METHODS

Initial development of the TEXP-Q was inspired by existing research. Items were formulated in accordance with consensus recommendations for developing patient-reported measures, and extra consideration was taken to ensure person-centredness. Psychometric evaluation comprised two phases: In phase I, data from cognitive interviews, content validity indexing, and judgement of an expert panel provided information on face and content validity. In phase II, data from a cross-sectional study conducted at eight adult diabetes outpatient clinics in Sweden (n = 163) allowed for explorative factor analysis (EFA), as well as calculation of content validity, reliability and responsiveness.

RESULTS

Combining results from cognitive interviews, content validity index values and expert panel judgement, a test version of TEXP-Q was developed, the content and face validity of which were considered good. This version consisted of 17 items answered on a five-point Likert scale, and three open-ended questions answered in free text. During EFA, four items were removed, and a three-factor solution was recognised as most adequate, accounting for 60% cumulative variance and one single cross-loading. After EFA, the instrument comprised 13 questions, divided into three latent factors. Cronbach's alpha for the complete instrument was 0.866, which indicates good internal consistency. Crohnbach's alpha approximated to 0.8 for all factors respectively.

CONCLUSION

TEXP-Q is a newly developed, person-centred instrument which has proven to be both valid and reliable when applied to youths with T1D. The questionnaire fills a need for instruments focusing on emerging adults' experiences of preparation for transition and transfer.

Health-related quality of life among adolescents with type 1 diabetes since the second wave of the COVID-19 pandemic in Germany

OBJECTIVE

The COVID-19 pandemic had an impact on everyday life and in general, reduced the health-related quality of life (HRQoL) of adolescents. In this study, we assess the HRQoL of adolescents with type 1 diabetes (T1D) in Germany since the second wave of the COVID-19 pandemic by using self-report and parent-proxy reports, to identify risk factors, to compare to peers and to examine the agreement of HRQoL between parents and their children.

METHODS

A total of 445 adolescents (12-18 years) and 413 parents participated in an anonymous cross-sectional survey conducted at three German diabetes centres from January 2021 to June 2022. Inclusion criteria were diabetes duration ≥1 year and German-speaking. Teen HRQoL was assessed by using self-report and parent-proxy report versions of the KIDSCREEN-10 index.

RESULTS

The majority of adolescents reported average (75.5%) HRQoL. Approximately 11.3% of teens reported high and 13.2% low HRQoL. Teen's female gender, older age, higher diabetes burden and parental depression symptoms contributed to lower self-reported HRQoL among teens. For parent-proxy reports, increasing diabetes burdens, parental depression symptoms, non-migrant status, high education and ketoacidosis contributed to lower scores on teen HRQoL. The mean scores of the KIDSCREEN-10 index for adolescents did not differ from the German norm. In comparison to healthy peers during the first wave of the pandemic, adolescents in the current study reported higher HRQoL. The overall teen-parent agreement was fair although parents reported significantly lower teen HRQoL than adolescents did.

CONCLUSIONS

HRQoL of most adolescents with T1D during the COVID-19 pandemic was average with parents reporting significantly lower scores. Self-reported and parent-proxy-reported HRQoL and the level of agreement due to different perspectives can provide important information for clinical care and intervention planning.

Transition From Childhood to Adult Care in Patients with Type 1 Diabetes: 20 Years of Experience From the Tübinger Transition Study

AIMS

Transition from pediatric to adult care is difficult for patients with chronic diseases. In this study, factors associated with metabolic control in childhood-onset type 1 diabetes (T1D) after transfer to adult care were analyzed.

METHODS

Overall, 224 persons with T1D were contacted yearly from 1998 to 2019. They voluntarily answered a questionnaire about their current hemoglobin A1c (HbA1c) levels, diabetes-associated complications, kind of care, living conditions, and family situation. Then, mixed longitudinal-cross-sectional analyses were carried out.

RESULTS

Overall, 190 patients answered at least once (mean age: 26.6 years). Diabetes complications were mentioned by 10 patients (5 microalbuminuria, 5 retinopathy). Most patients (92.6%) were in diabetes-specific care during the first year after transfer, with a trend to leave diabetes-specific care during the observation period. Patients in diabetes-specific care displayed lower HbA1c levels (%/mmol/mol) (7.1/54 vs. 7.5/58). An important predictor for HbA1c after transfer was HbA1c during the year before transfer (r=0.67, p <0.001). Patients living alone showed no difference in HbA1c levels from those living with their parents. Married patients had lower HbA1c levels (7.0/53 vs. 7.3/56, p<0.05) than unmarried ones. Patients with children (15.8%) presented lower HbA1c levels (6.9/52 vs. 7.3/56, p <0.01) than those without.

CONCLUSIONS

Good metabolic results are favored in patients followed-up in specialized care, are married, and are parents. We recommend transfer to a diabetologist with experience in T1D at an individual age.

A Comparison of Depressive Symptom Presentation in Adolescent Type 1 Diabetes and Pediatric Primary Care Samples

Background

Depression is a common comorbidity in adolescents with type 1 diabetes (T1D). It is unclear if patterns of responses from questionnaires used to screen for depressive symptoms are influenced by the burden of living with T1D and/or the consequences of hyperglycemia. Based on this gap in the adolescent research, we sought to identify potential differences in depression screening response patterns between adolescents with and without T1D and relate response patterns with glycemic outcomes.

Methods

Using a retrospective case-control design, we analyzed electronic health records for age, sex, and race-matched adolescents 13-18 years of age from a pediatric diabetes clinic (n = 477) and a pediatric primary care clinic (n = 477) in the United States. Adolescents in both settings were screened for depressive symptoms during the same time period using the Patient Health Questionnaire-9 (PHQ-9).

Results

Participant demographics for matched characteristics were: 53.5% male, 71.7% White, median age 13.0 (interquartile range = 13.0, 14.0). After controlling for type of insurance, adolescents with T1D were more likely to have higher total PHQ-9 scores (odds ratio (OR) = 1.51, 95% CI = 1.17, 1.98, p = 0.002) and higher somatic subscores (OR = 1.57, 95% CI = 1.20, 2.05, p = 0.001) compared to the primary care sample. The pattern of item endorsement greater than "not at all" indicated that adolescents with T1D were more likely to have higher values for somatic items such as "trouble falling asleep" and "feeling tired" than those in the primary care sample. Item-total correlations and Cronbach's α indicated that all items were contributing to the overall score in the same manner in each group.

Conclusions

Symptom endorsement for sleep and fatigue were higher for adolescents with T1D and without T1D. Study results support the need for further examination of the origins of somatic symptoms in T1D and for an additional examination of the specificity of depression screening instruments used in routine pediatric diabetes care.

The Impact of a Low-Carbohydrate Diet on Micronutrient Intake and Status in Adolescents with Type 1 Diabetes

OBJECTIVE

The aim of this study was to evaluate the macronutrient and micronutrient intake and status in youth with type 1 diabetes mellitus (T1DM) following the consumption of a low-carbohydrate diet (LCD).

RESEARCH METHODS AND PROCEDURES

In a prospective intervention clinical trial, adolescents with T1DM using a continuous glucose monitoring device were enrolled. Following a cooking workshop, each participant received a personalized diet regime based on LCD (50-80 g carbohydrate/day). A Food Frequency Questionnaire was administered, and laboratory tests were taken before and 6 months following the intervention. Twenty participants were enrolled.

RESULTS

The median age was 17 years (15; 19), and the median diabetes duration was 10 years (8; 12). During the six-months intervention, carbohydrate intake decreased from 266 g (204; 316) to 87 g (68; 95) (p = 0.004). Energy intake, the energy percent from ultra-processed food, and fiber intake decreased (p = 0.001, p = 0.024, and p < 0.0001, respectively). These changes were accompanied by declines in BMI z-score (p = 0.019) and waist-circumference percentile (p = 0.007). Improvement was observed in the median HbA1c from 8.1% (7.5; 9.4) to 7.7% (6.9; 8.2) (p = 0.021). Significant declines below the DRI were shown in median intake levels of iron, calcium, vitamin B1, and folate.

CONCLUSIONS

The LCD lowered ultra-processed food consumption, BMI z-scores and the indices of central obesity. However, LCDs require close nutritional monitoring due to the possibility of nutrient deficiencies.

Comparison of diabetes distress and depression screening results of emerging adults with type 1 diabetes onset at different ages: findings from the German early-onset T1D study and the German Diabetes Study (GDS)

BACKGROUND

Diabetes distress is increasingly considered one of the most important psychosocial issues in the care of people with type 1 diabetes (T1D). We analyse whether diabetes distress and depression screening results of emerging adults are associated with the age at T1D onset.

METHODS

Data were taken from two cohort studies conducted at the German Diabetes Center, Düsseldorf, Germany. The 18-30-year-old participants had an age at onset either before the age of 5 years (childhood-onset long-term T1D study group, N = 749) or during adulthood (adult-onset short-term T1D study group from the German Diabetes Study (GDS), N = 163). Diabetes distress and depression screening were analysed by means of the 20-item Problem Areas in Diabetes (PAID-20) scale and the nine-item depression module from the Patient Health Questionnaire (PHQ-9). The average causal effect of age at onset was estimated by a doubly robust causal inference method.

RESULTS

The PAID-20 total scores were increased in the adult-onset study group [potential outcome mean (POM) 32.1 (95% confidence interval 28.0; 36.1) points] compared to the childhood-onset study group [POM 21.0 (19.6; 22.4) points, difference 11.1 (6.9; 15.3) points, p<0.001] adjusted for age, sex and haemoglobin A1c (HbA1c) levels. Moreover, more participants in the adult-onset group [POM 34.5 (24.9; 44.2) %] than in the childhood-onset group [POM 16.3 (13.3; 19.2) %] screened positive for diabetes distress [adjusted difference 18.3 (8.3; 28.2) %, p<0.001]. The PHQ-9 total score [difference 0.3 (-1.1; 1.7) points, p=0.660] and the proportion of participants with a positive screening result for depression [difference 0.0 (-12.7; 12.8) %, p=0.994] did not differ between the groups in the adjusted analyses.

CONCLUSIONS

Emerging adults with short-term type 1 diabetes screened positive for diabetes distress more often than adults with type 1 diabetes onset during early childhood when age, sex and HbA1c values were considered confounding factors. Accounting for age at onset or the duration of diabetes may help explain the heterogeneity in the data when psychological factors are examined.

[Diabetes mellitus in childhood and adolescence (Update 2023)]

In contrast to adults, type 1 diabetes mellitus (T1D) is the most frequent form of diabetes in childhood and adolescence (> 90%). After diagnosis the management of children and adolescents with T1D should take place in highly specialized pediatric units experienced in pediatric diabetology. The lifelong substitution of insulin is the cornerstone of treatment whereby modalities need to be individually adapted for patient age and the family routine. In this age group the usage of diabetes technology (glucose sensors, insulinpumps and recently hybrid-closed-loop-systems) is recommended. An optimal metabolic control right from the start of therapy is associated with an improved long-term prognosis. Diabetes education is essential in the management of patients with diabetes and their families and needs to be performed by a multidisciplinary team consisting of a pediatric diabetologists, diabetes educator, dietitian, psychologist and social worker. The Austrian working group for pediatric endocrinology and diabetes (APEDÖ) and the ISPAD (International Society for Pediatric and Adolescent Diabetes) recommend a metabolic goal of HbA1c ≤ 7.0%, ((IFCC) < 53 mmol/mol), and a "Time in range" > 70% for all pediatric age groups without the presence of severe hypoglycemia. Age-related physical, cognitive and psychosocial development, screening for associated diseases, avoidance of acute diabetes-related complications (severe hypoglycemia, diabetic ketoacidosis) and prevention of diabetes-related late complications to ensure high quality of life are the main goals of diabetes treatment in all pediatric age groups.

Evaluation of the nutritional status of children with type 1 diabetes and their healthy siblings

BACKGROUND

Although there are studies evaluating the psychological adjustment of healthy children when their siblings have type 1 diabetes mellitus (T1DM), no study evaluating their nutritional status exists. Thus, this study aimed to determine the nutritional status of children with T1DM and their healthy siblings.

MATERIAL AND METHODS

Data from a control group, healthy siblings, and patients who were followed and treated for T1D in the Paediatric Gastroenterology and Paediatric Endocrinology outpatient clinics of the Health Sciences University Gülhane Medical Faculty between November 2019 and November 2020 were analysed and compared. The groups were compared in terms of nutritional characteristics, daily macro and micronutrient intakes and classified according to their body mass index (BMI) Z-scores.

RESULTS

The study population consisted of 29 children with T1DM (51.7% female, 48.3% male; age: 11.00 ±3.66 years), 36 healthy siblings of children with T1D (50% female, 50% male; age: 9.61 ±4.84 years), and a control group of 58 healthy children (51.7% female, 48.3% male; age: 10.68 ±3.01years).The BMI Z-score of 28.6%of healthy siblings and 25% of children with T1D was > 1 SD or overweight. All of the control group children were of normal weight. None of the children were obese; however, the overweight rate was significantly higher in the healthy siblings and diabetes groups compared to the control group (p = 0.012). Daily energy intake (%) was significantly higher in the control group than in the healthy siblings (p < 0.001).

CONCLUSIONS

A quarter of the children with T1D over five years of age were overweight. In addition, healthy siblings were found to have higher BMI Z-scores than controls. This is the first study to evaluate the nutritional status of siblings of patients with T1D and will hopefully lead to more comprehensive studies that will also assess their daily exercise and physical activity.