A summer vacation from diabetes: evidence from a clinical trial

Deterioration in glycemic control on schooldays among children and adolescents with type 1 diabetes: A continuous glucose monitoring-based study

BACKGROUND

To investigate the effect of school life by comparing the glycemic control between holidays and schooldays in children and adolescents with type 1 diabetes (T1D).

METHODS

This observational study enrolled school-aged students with T1D (aged 6-19) from September 2019 to July 2021. Continuous glucose monitoring (CGM) records were processed and divided into holidays and schooldays. Other information was collected via questionnaires. We compared the results using paired T-test, Wilcoxon paired test and logistic regression analysis.

RESULTS

78 paticipants were included (40 boys, mean age 9.95 years). A total of 142,945 h of CGM data were analyzed. Overall, TIR (3.9-7.8 mmol/L) during holidays was better than schooldays [56.97 (SD 15.03) vs. 55.87 (15.06), %, p = 0.039]. On nocturnal (0-6 am) glycemic fluctuation, TIR was longer in children aged 6-10 [60.54 (17.40) vs. 56.98 (SD 16.32), %, p = 0.012] during holiday and TAR (7.8 mmol/L) was shorter [31.54 (17.54) vs. 35.54 (16.95), %, p = 0.013], compared with schooldays. In adolescents aged 10-19 years, TAR was also significantly shorter during holidays. Stratified analysis showed that girls, patients with longer duration, and insulin pump users had more pronounced worsening of nighttime glycemia on schooldays. Logistic regression analysis showed that girls had higher risk of worse nocturnal glycemic control [3.26, 95% CI: (1.17, 9.72), p = 0.027] and nocturnal hyperglycemia [OR = 2.95, 95% CI: (1.08, 8.56), p = 0.039], compared to boys.

CONCLUSIONS

Children and adolescents with T1D were found to have worse glycemic control in nighttime during schooldays.

Effects of subclinical emotional and behavioral problems on metabolic control in adolescents with type 1 diabetes: Role of maternal and adolescent personality traits

BACKGROUND

Personality traits of adolescents with type 1 diabetes mellitus (T1DM) and those of their mothers may lead to poor glycemic control through psychiatric comorbidity. However, it is not yet known how the personality traits of adolescents with T1DM and those of their mothers affect metabolic control in the absence of or before the development of psychiatric disorders. We aimed to determine the effects of subclinical emotional and behavioral problems, as well as maternal and own personality traits, on metabolic control in adolescents with T1DM.

METHODS

A total of 48 adolescents with diabetes (19 females and 29 males), with a median age of 14 years, who did not meet diagnostic criteria for a psychiatric condition, and their mothers completed the Junior Temperament and Character Inventory (J-TCI) as well as the adolescent and parent forms of the Strengths and Difficulties Questionnaire (SDQ) and the TCI for adults. The mean HbA1c levels measured in the past year were obtained from medical records.

RESULTS

Personality traits and the emotional and behavioral difficulties in adolescents with poor metabolic control were similar to those with good metabolic control (p>.05). However, the self-directedness and cooperativeness subscale scores of the TCI completed by the mothers of those in the poor metabolic control group were significantly lower than the others: 25.5 vs. 30.4; t(39)= 3.737, p= .001, and 27.3 vs. 31.5; t(46)= 2.759, p= .008; respectively.

CONCLUSION

Our study showed that adolescents' personality and subclinical symptoms were not related to HbA1c levels in the absence of psychiatric comorbidity, while some maternal personality traits were associated with metabolic control. Management of T1DM should be tailored to adolescents and their needs with the proper involvement of mothers.

Psychometric Properties of the Problem Areas in Diabetes: Teen and Parent of Teen Versions

Objective

This study adds to the literature on the psychometric properties of the Problem Areas in Diabetes-Teen (PAID-T) and Parent (P-PAID-T) Versions. It also aims to shorten the measures of diabetes-specific distress, determine construct validity, and establish cutoff scores.

Methods

Data are from two independent studies (N = 1,265). Adolescent-caregiver dyads completed measures of emotional distress, diabetes strengths, hemoglobin A1c, blood glucose checks, and average blood glucose. Exploratory and confirmatory factor analyses assessed factor structures for each measure. Correlational analyses provided support for concurrent validity. Receiver-operating characteristic curves identified cutoff scores based on clinically meaningful groups identified with latent profile analysis.

Results

Analyses supported a 14-item PAID-T and a 15-item P-PAID-T, with preliminary cutoff scores ≥44 and ≥54, respectively. Measures were associated with emotional and health outcomes as hypothesized.

Conclusions

The PAID-T and P-PAID-T are valid, reliable, and useful measures of diabetes-specific distress for teenagers with type 1 diabetes and parents of teenagers.

Clinical Use of Degludec in Children and Adolescents with T1D: A Narrative Review with Fictionalized Case Reports

The use of insulin in children and adolescents with type 1 diabetes (T1D) is a challenge because of the heterogeneity of these patients and their lifestyles, with consequent unpredictability in blood glucose levels. A new ultra-long-acting basal insulin, insulin degludec (degludec), has the potential to mitigate some of these challenges, notably variability in the glucose-lowering action of the basal insulin component of an insulin regimen, and consequent risks of hypo- and hyperglycemia. However, the protracted half-life and steady state pharmacokinetics of degludec potentially bring some new challenges. In particular, the adjustment of therapy in response to commonly encountered clinical situations might require a different approach when degludec is used in place of other currently used basal insulins in this challenging patient population. The purpose of this article is to guide clinicians through a series of case histories in the use of this insulin. These include, but are not limited to, how to initiate, titrate, switch from other basal insulin or pump therapy; how to alleviate difficulties arising as a result of unpredictable lifestyle/habits; and how to maintain treatment following diabetic ketoacidosis. The guidance presented in this review illustrates that degludec is a good option for a diverse range of children and adolescents with T1D, providing much needed flexibility in the treatment of this challenging patient population.Funding Novo Nordisk.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Diabetes Distress Among Adolescents with Type 1 Diabetes: a Systematic Review

Diabetes distress (DD) refers to the negative emotions arising from living with diabetes and the burden of self-management. Among adults, the prevalence and significance of DD are well established, but this is not the case among adolescents. This systematic review investigated among adolescents with type 1 diabetes: the prevalence of DD; demographic, clinical, behavioral and psychosocial correlates of DD and interventions that reduce DD. Consistent with adult studies, around one third of adolescents experience elevated DD and this is frequently associated with suboptimal glycemic control, low self-efficacy and reduced self-care. Three measures of DD have been developed specifically for adolescents, as those designed for adults may not be sufficiently sensitive to adolescent concerns. Interventions reducing DD in the short term include strategies such as cognitive restructuring, goal setting and problem solving. Further work is needed to investigate sustainability of effect. Rigorous research is needed to progress this field among adolescents.

A Review of Diabetes Mellitus–Specific Family Assessment Instruments

Family dynamics and attributes are increasingly recognized as affecting management of diabetes mellitus (DM); however, little research has been done on the validity and usefulness of family assessment instruments (FAIs). This article reviewed the literature that employs DM-specific FAIs and evaluates whether the instruments comprehensively captured family attributes/processes and were robust enough to be useful in understanding the relationship between family attributes/issues and DM-related health care. Studies using eight instruments were identified through a search of literature published from 1982 to 2010 and were analyzed with criteria derived from the measurement and family literatures. The findings of this study revealed that DM-specific FAIs yield useful data about family-related phenomenon; however, some domains of DM-specific care, such as family dynamics/functioning, were not overtly measured. Suggestions for improving DM-specific FAIs are provided and a rationale for why DM-specific and non-DM-specific FAIs is needed to fully measure family issues related to family dynamics/attributes on DM patient care.

Preparing for transition? The allocation of oral medication regimen tasks in adolescents with renal transplants

A mixed-methods design was utilized to examine strategies that families use to manage the post-transplant oral medication regimen of adolescents with renal transplants. Seventeen adolescents and their caregivers were administered structured interviews assessing the tasks that families identified as comprising the oral medication regimen, how tasks were allocated across family members and how the dyad decided on the allocation of tasks. Adherence was assessed via electronic pill bottles and calculated by dividing the number of doses taken by those prescribed. Patients and their caregivers identified the following tasks as part of the oral medication regimen: filling the pillbox (71%), calling for refills (65%) and verifying that the pillbox is filled correctly (47%). Adult caregivers were primarily responsible for managing the medication regimen for the majority of adolescents (70%). Secondary analyses revealed that the number of oral medication regimen tasks identified by the dyad was significantly associated with patient adherence. Our findings highlight the need to bolster efforts to develop methods to quantitatively assess and promote self-management skills among adolescents with renal transplants.

The effect of family routines on care for inner city children with asthma

This article provides the results of a study utilizing baseline data from the School-Based Asthma Therapy Trial, an ongoing comprehensive school-based intervention for urban children. We examined the effect of family routines as measured by the Asthma Routines Questionnaire on asthma care measures of trigger control and medication adherence, as well as on parental quality of life. We found that families with more asthma routines had better adherence with preventive medications (r = .36) and less exposure to environmental triggers (r = -.22). These findings suggest that assisting families in developing routines around asthma care might improve preventive care for urban youth.

Allocation of family responsibility for illness management in pediatric HIV

OBJECTIVE

The purpose of the study is to describe allocation of responsibility for illness management in families of children and adolescents perinatally infected with HIV.

METHODS

A total of 123 youth (ages 8-18) and caregivers completed family responsibility and medication adherence questionnaires as part of a substudy of Pediatric AIDS Clinical Trials Group protocol 219c.

RESULTS

Approximately one-fourth of the youth reported being fully responsible for taking medications. A smaller percentage of caregivers reported full youth responsibility. Older youth and caregivers of older youth reported higher degree of youth responsibility for medication-related tasks, though age was unrelated to adherence. Caregiver report of greater responsibility for medications was associated with better adherence.

CONCLUSIONS

Caregivers are likely to transition responsibility for HIV care to older youth but this transition was not always successful as evidenced by poor medication adherence. Interventions supporting successful transition may improve adherence and subsequently health outcomes in pediatric HIV.

High volume-low intensity exercise camp and glycemic control in diabetic children

AIM

To evaluate the effects of the designed regime encompassing high volume-low intensity physical activity programme on glycemic control in diabetic children, 20 subjects (age 12.81 +/- 2.14) spent 2 weeks in a controlled environment of a summer camp.

METHODS

An exercise physiologist and a kinesiology specialist programme and conducted the three exercise sessions a day. Total daily caloric intake was controlled and the blood glucose was monitored four times a day with special concern for hypoglycaemia episodes. Short and long-term effects (HbA1c) of the summer camp were evaluated 10 days and 2 months following programme completion. The insulin dosage was not lowered at the beginning of the camp for everyone, but it was individually modified according to the blood glucose monitoring.

RESULTS

Initial HbA1c was 8.28 +/- 1.3% and decreased to 7.92 +/- 1.42% measured 10 days after the camp (P = 0.023) while the number of children with the satisfactory HbA1c level lower than 7.5% doubled. HbA1c increased again 2 months following the camp. The average blood glucose concentrations decreased in the last days of the camp when compared with the first day in three out of four daily measurements (P < 0.05). There were only two clinically manifested hypoglycaemia episodes recorded.

CONCLUSION

With a low rate of hypoglycaemia crisis and better glycemic control the proposed programme was found to be satisfactory but the downside was that the duration of the effects was too short. With no participation in organised exercise programmes and with absence of controlled nutrition, the beneficial effects of the camp disappeared within 2 months after the camp.

Gender differences in adherence and metabolic control in urban youth with poorly controlled type 1 diabetes: the mediating role of mental health symptoms

OBJECTIVE

To examine gender differences in adherence and metabolic control and test the mediating role of mental health symptoms in a sample of predominantly African-American, low-income youth with chronically poor metabolic control.

METHODS

Baseline questionnaire data from an intervention study were collected from 119 youth and their primary caregiver.

RESULTS

Boys had worse adherence than girls, but there were no gender differences in hemoglobin A1C (HbA1C). Boys had more externalizing symptoms, whereas girls had more anxiety; there were no gender differences in depression. Externalizing symptoms were associated with poor adherence and metabolic control. Although anxiety was correlated with poor adherence, this relationship was not significant in the invariate analysis. Results of structural equation modeling (SEM) suggested that externalizing symptoms mediated the relationship between gender and adherence.

CONCLUSIONS

Results suggest that gender differences in adherence may be attributed, in part, to gender differences in externalizing symptoms in urban youth with poor metabolic control. Interventions targeting these symptoms may be necessary to improve adherence and HbA1C in both boys and girls.

Fructosamine levels demonstrate improved glycemic control for some children attending a diabetes summer camp

Residential summer camps for youths with diabetes may have a positive effect on glycemic control. Hemoglobin A1c (HbA1c) is considered the best measure of control, but it reflects too long a period to evaluate a camp session. The fructosamine test reflects control over a period of 2-3 wk and may be ideal for this purpose. A portable device was used to examine the relationship between 2 wk of glycemic control and the change in fructosamine in order to determine whether control improved at camp. Thirty children, 8-12 yr old, were studied during a 2-wk session of a diabetes summer camp. Pre-camp HbA1c levels were obtained from the childrens' physicians. Each camper measured his/her blood glucose four times daily. Insulin doses were readjusted frequently by camp physicians. Each child's fructosamine was measured at the beginning and end of camp. The baseline fructosamine correlated with HbA1c. The final fructosamine correlated with the 2-wk mean glucose. The subgroup who started camp in below average glycemic control improved their fructosamine levels by the end of camp. Those who started camp in better control did not change. Without continuous glucose monitoring, it is impossible to accurately determine how well fructosamine reflects glucose levels. In this study, fructosamine correlated with the mean glucoses and with an HbA1c obtained prior to camp. Fructosamine appears to be a valid measure of glycemic control and being at camp was at least transiently beneficial to the children who needed it most.