Type 1 diabetes in young adulthood

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Impact of psychiatric disorders on the risk of diabetic ketoacidosis in adults with type 1 diabetes mellitus: a propensity score matching case-control study

PURPOSE

This study aims to evaluate the association between psychiatric disorders and diabetic ketoacidosis (DKA) in patients with type 1 diabetes (T1D) treated at a tertiary care hospital.

METHODS

A propensity score-matched case-control study was conducted, comprising a total sample of 194 participants (97 DKA cases and 97 controls without DKA). Comprehensive data were collected on clinical, anthropometric, and socioeconomic characteristics, and psychiatric disorders were classified according to international standards.

RESULTS

The mean age of the participants was 47.4 ± 17.7 years, with 55.6% being female. Psychiatric disorders were identified in 16.5% of the study population. The prevalence of psychiatric disorders was significantly higher in DKA cases compared to controls (24.7% vs. 7.2%, p < 0.001). Conditional logistic regression models revealed that the association between psychiatric disorders and DKA was not independent of HbA1c levels. Additionally, in HbA1c-stratified analyses, patients with psychiatric disorders developed DKA at lower HbA1c levels compared to controls.

CONCLUSION

Psychiatric disorders significantly increase the risk of DKA in adults with T1D, particularly among those with less elevated HbA1c levels. These findings highlight the critical importance of addresing psychiatric comorbidities in the management of T1D, given the severe implications and significant healthcare resource utilization associated with DKA.

Quality of life in young adults with type 1 diabetes

Introduction

Challenges of young adulthood with type 1 diabetes (T1D) include transitioning to adult care, increased T1D self-management responsibilities, and normal developmental transitions. Recognizing patterns of health-related quality of life (HRQOL) across a demographically and clinically broad range of young adults with T1D may help identify who needs additional support as they transfer to adult healthcare. We hypothesized that young adults from specific demographic and clinical groups would report lower HRQOL.

Methods

At baseline of a behavioral RCT (≤2 months after last pediatric T1D clinic visit), 100 young adults (Mage=19.9 ± 1.3, MA1c=8.8 ± 2.0 %) self-reported demographics and HRQOL; A1c was analyzed via point of care or dried blood spot. ANOVAs and t-tests were used to compare HRQOL by demographic (gender, race/ethnicity, insurance, school enrollment) and clinical variables (device use, A1c).

Results

Diabetes-specific HRQOL differed significantly by gender and school enrollment; females and young adults enrolled in school reported higher HRQOL. There were no significant differences in HRQOL across race/ethnicity, insurance type, and diabetes technology use.

Conclusion

Monitoring HRQOL may be helpful to identify diabetes-specific psychosocial needs during the transition from pediatric to adult healthcare. Patterns suggest males and those not in school may benefit from additional support.

Socio-cognitive determinants affecting insulin adherence/non-adherence in late adolescents and young adults with type 1 diabetes: a systematic review

Non-adherence to insulin treatment is common in adolescents and young adults (AYAs) with type 1 diabetes (T1D) and is associated with increased morbidity and mortality. However, the socio-cognitive determinants (SCDs) of adherence in AYAs with T1D are less frequently represented in systematic reviews. This systematic review aimed to investigate the key SCDs associated with adherence/non-adherence to insulin treatment in AYAs in the age range of 17-24 years with T1D. A systematic review in PubMed, Embase, Web of Science, and PsycINFO was conducted. The search took place from 2021, to January 1st, 2022, and was repeated on June 5-7, 2022 and from July 18 to July 24, 2023. The methodological quality of studies was assessed by the National Heart, Lung, and Blood Institute quality assessment tool for observational cohort and cross-sectional studies. Six articles representing 973 AYAs with T1D were included for data extraction. The identified SCDs included risk perceptions, attitude, family and friends' social support, self-efficacy, and information factors. However, there was inconsistency in correlational findings among studies. The identified SCDs influencing insulin adherence in AYAs with T1D could serve as targets for patients' consultations and tailored interventions to improve adherence and overall health outcomes, as well as for policymakers to integrate these interventions into diabetes care planning. However, further research in the area of factors affecting insulin adherence in quality-designed studies that use detailed and comprehensive measures for assessing adherence is needed.

A Theory of Transitions Influencing Diabetes Self-management Among Emerging Adults With Type 1 Diabetes

Emerging adults with type 1 diabetes are experiencing numerous transitions, potentially affecting diabetes self-management. For example, when transitioning to college, these emerging adults may experience changes in their daily routines and usual reminders or triggers for habitual behavior such as checking blood glucose levels. In turn, these emerging adults may omit checking glucose levels, impacting decisional and adaptational diabetes self-management behavior associated with their insulin dose or bolus. Thus, we propose a theory on transitions influencing daily routines, diabetes self-management habitual behavior triggers, and, in turn, diabetes self-management habitual and decisional/adaptational behaviors for emerging adults with type 1 diabetes.

International Society for Pediatric and Adolescent Diabetes Clinical Practice Consensus Guidelines 2024: Diabetes Technologies - Insulin Delivery

The International Society for Pediatric and Adolescent Diabetes (ISPAD) guidelines represent a rich repository that serves as the only comprehensive set of clinical recommendations for children, adolescents, and young adults living with diabetes worldwide. This chapter builds on the 2022 ISPAD guidelines, and summarizes recent advances in the technology behind insulin administration, with special emphasis on insulin pump therapy, especially on glucose-responsive integrated technology that is feasible with the use of automated insulin delivery (AID) systems in children and adolescents. The International Society for Pediatric and Adolescent Diabetes (ISPAD) guidelines represent a rich repository that serves as the only comprehensive set of clinical recommendations for children, adolescents, and young adults living with diabetes worldwide. This chapter builds on the 2022 ISPAD guidelines, and summarizes recent advances in the technology behind insulin administration, with special emphasis on insulin pump therapy, especially on glucose-responsive integrated technology that is feasible with the use of automated insulin delivery (AID) systems in children and adolescents.

DiaBetter Together: Clinical trial protocol for a strengths-based Peer Mentor intervention for young adults with type 1 diabetes transitioning to adult care

BACKGROUND

Type 1 diabetes (T1D) management is challenging for young adults, who are expected to transfer from the pediatric to adult T1D healthcare system while also managing typical developmental demands (e.g., social, financial, work/school, residential). Many young adults have extended gaps in care before following up in adult care, increasing risk for poor health outcomes. There are few evidence-based programs to support young adults with T1D to promote a timelier transition during this period. This paper reports on the design of DiaBetter Together, a randomized controlled trial to evaluate a 12-month Peer Mentor-delivered intervention compared to usual care among young adults with T1D during the transfer from pediatric to adult care.

METHODS

One-hundred young adults (age 17-25) with T1D and 29 Peer Mentors enrolled in this randomized clinical trial. Peer Mentors are experienced, older young adults with T1D, trained by the study team to share transition experiences and strategies to successfully navigate the adult healthcare system, help young adults prepare for the first adult care visit, and use strengths-based support strategies to teach and model skills for managing T1D-related challenges.

RESULTS

The primary outcome of the trial is HbA1c, and secondary outcomes include time to adult care, engagement in diabetes self-management behaviors, and psychosocial well-being.

CONCLUSION

The goal of this research is to evaluate a developmentally appropriate, supportive intervention that can improve T1D self-management and successful transfer of care during the difficult young adult years and promote optimal T1D health outcomes.

Sleep Health Composite and Diabetes Symptom Burden in Young Adults With Type 1 Diabetes

INTRODUCTION

Multiple individual sleep health dimensions (satisfaction, regularity, and duration) are associated with diabetes symptoms, precursors to micro-and macrovascular complications, among young adults with type 1 diabetes mellitus (T1DM). Nearly half of young adults with T1DM develop vascular complications; however, modifiable contributors of diabetes symptoms, including sleep health, have been understudied.

METHODS

This cross-sectional quantitative descriptive study involved the completion of multiple validated self-report questionnaires and the collection of raw continuous glucose monitor and diary data over a 14-day period. The sleep health composite score was calculated by summing the number of dimensions with "good" sleep health. Chronotype was estimated with the 19-item Morningness-Eveningness Questionnaire. Multiple linear regression analyses were conducted to evaluate the associations between the independent variables (sleep health composite and chronotype) and diabetes symptom burden. Covariates, including age, race, sex at birth, T1D duration, continuous subcutaneous insulin infusion use, and hemoglobin A1C (HbA1C), were considered to determine their contribution to these relationships.

RESULTS

One hundred nineteen young adults with T1DM who were aged 18 to 26 years were included in this study from 2 cohorts. Higher sleep health composite scores were associated with a lower overall diabetes symptom burden, even after adjusting for covariates in the linear regression models. Initially, a later chronotype was linked to a higher diabetes symptom burden, but this association became insignificant after accounting for HbA1C levels.

CONCLUSION

Improving multiple dimensions of sleep health may alleviate the diabetes symptom burden among young adults with T1DM.

Self-Management and Relationships: Perspectives of Young Adults With Chronic Conditions and Their Peers

Because their disease is largely managed in the private environment, people with chronic conditions perform "chronic homework." The environment with which self-management is coordinated forms a kind of "chronic care infrastructure" in dealing with the disease and, in the case of young adults with chronic conditions (YACCs), is essentially formed by peers. The article investigates how YACCs handle their illness in the context of their peer relationships and how peers see their own role in the context of the YACCs' self-management. What do chronic homework and chronic care infrastructures look like, if the chronic conditions concern young adults in comparatively unstable and non-committal relationships with their peers? Episodic interviews were conducted with 60 YACCs (with type 1 diabetes, cancer, chronic inflammatory bowel disease, and rare conditions) and 30 peers. The interviews were analyzed using thematic coding. The YACCs' statements were compared to the peer perspectives on a case-by-case basis. We found that peers differ in the extent to which they seek to monitor or control the YACCs' self-management. We identified three groups of YACCs: (a) those who focus on their health needs; (b) those who seek to balance their disease management with their need for sociability and belonging; and (c) those who deprioritize their illness in their everyday life in favor of peer acceptance. The multi-perspective approach to YACCs' and their peers' experiences with self-management on the one hand and referring to a range of chronic conditions on the other allows to analyze this issue in a complex and comprehensive way.

Macroergonomic components of the patient work system shaping dyadic care management during adolescence: a case study of type 1 diabetes

The role of the social, physical, and organisational environments in shaping how patients and their caregivers perform work remains largely unexplored in human factors/ergonomics literature. This study recruited 19 dyads consisting of a parent and their child with type 1 diabetes to be interviewed individually and analysed using a macroergonomic framework. Our findings aligned with the macroergonomic factors as presented in previous models, while highlighting the need to expand upon certain components to gain a more comprehensive representation of the patient work system as relevant to dyadic management. Examples of design efforts that should follow from these findings include expanding existing data sharing options to include information from the external environment and capitalising on the capabilities of artificial intelligence as a decision support system. Future research should focus on longitudinally assessing patient work systems throughout transition periods in addition to more explicitly exploring the roles of social network members.

Parent and Young Adult Perspectives About the Transition to College During the COVID-19 Pandemic

PURPOSE

The purpose of this study was to describe the influence of COVID-19 on parents and their young adults with type 1 diabetes as they navigated the college environment during the COVID-19 pandemic.

PARTICIPANTS

A sample of 9 college students with type 1 diabetes and their parents were recruited to participate in interviews via purposive sampling methodology.

METHODS

A descriptive, qualitative study was conducted using semi-structured questions via recorded video conferencing interviews.

RESULTS

Three themes related to navigating type 1 diabetes at college during the pandemic emerged: (1) isolation and mental health: COVID-19-related isolation and loneliness; (2) risk and exposure to COVID-19: balancing risk of COVID-19 with type 1 diabetes; and (3) management of type 1 diabetes on campus during the pandemic: academics, university policies, and their impact on type 1 diabetes.

CONCLUSIONS

Students with type 1 diabetes and their parents had to navigate a complex set of concerns that extended beyond the usual challenges of diabetes management during the COVID-19 pandemic. Providers must provide additional support and incorporate education about type 1 diabetes management strategies to families affected by large-scale health crises.

Parents' perspectives of factors affecting parent-adolescent communication about type 1 diabetes and negotiation of self-management responsibilities

Adolescence is an important time in which young people take on type 1 diabetes (T1D) self-management responsibility. Parents are key facilitators of this process. Little is known about parents' experiences of communicating with their children about T1D during adolescence. Semi-structured interviews were conducted with 32 parents (24 mothers and 8 fathers) of adolescents (11-17 years) living with T1D to explore how parents communicate about T1D and self-management with their adolescent children. Parents were recruited through two national child and adolescent diabetes and endocrine clinics and online advertisement through a national diabetes advocacy organisation. Interviews were transcribed verbatim and thematically analysed. Six themes were identified: parent factors, quality of the parent-adolescent relationship, communication strategies, adolescent factors, communication triggers and family/system factors. Understanding factors that impact communication about self-management between parents and adolescents will enable healthcare professionals to provide support and targeted interventions as parent and adolescent roles change over time.

Health Literacy Among Young People With Type 1 Diabetes: A Qualitative Study of Patient Involvement

OBJECTIVE

This qualitative study explored the challenges and knowledge gaps among Danish youth with type 1 diabetes and subsequently introduced an information program to empower these youth in their diabetes self-management.

RESEARCH DESIGN AND METHODS

Nine young patients 18-25 years of age who were diagnosed with type 1 diabetes, living independently, or cohabiting with a partner were included. Relevant participants were invited by mail or telephone. Group interviews were conducted to uncover the specific knowledge requirements essential for improving their diabetes health literacy. Based on these interviews, four education sessions were held.

RESULTS

The participants identified pertinent topics, including alcohol consumption, blood glucose control, educational and employment aspects, nutrition, sexuality, pregnancy, relationships, and interactions with health care professionals (HCPs). Notably, the participants expressed a preference for personalized interactions over information dissemination through digital platforms such as mobile applications. Building on this insight, we organized four sessions to provide education on the identified subjects. These sessions were designed to facilitate networking among participants and offer them the opportunity for discussion. Although invitations were extended to all individuals aged 18-25 years with type 1 diabetes (n = 52), only 13 patients and seven relatives participated. The feedback from attendees was overwhelmingly positive. Reasons for nonparticipation included forgetfulness or a reluctance to engage in group settings.

CONCLUSION

Young people with type 1 diabetes appreciate personal contact with HCPs. They do not want to receive knowledge via digital apps and virtual media but instead to meet with equals. However, it remains difficult to involve them in social events. The problem of how to create contact with young people with type 1 diabetes to strengthen their health literacy remains unsolved, and there is a need for further innovative initiatives.

Partnered Recruitment: Engaging Individuals With Lived Experience in the Recruitment of Co-Design Participants

BACKGROUND

Young adults with type 1 diabetes (T1D) face complex health challenges, including a heightened risk for distress. To counter this distress, there is a need to develop accessible, acceptable comprehensive care solutions that integrate diabetes and mental health care to enhance self-efficacy and counter mental health challenges in this population.

OBJECTIVE

To describe the engagement of individuals with lived experience of T1D and mental health challenges in the development of a recruitment strategy to support the co-design of an innovative integrated care programme.

RESULTS

Seven individuals with lived experience formed a Partner Advisory Council (PAC) to recruit young adults (18-29 years old) living with T1D, their friends or family and health researchers and professionals in co-design interviews (n = 19) and co-design events (n = 12). The PAC played a key role in developing a comprehensive recruitment strategy, overcoming traditional barriers and stigmas in the design of an integrated model of care.

CONCLUSION

Assuming the presence of mental health challenges in young adults living with T1D during recruitment had far-reaching impacts on the development of a whole-person and integrated diabetes and mental health care solution. The efficient recruitment of this sample provided invaluable insights into the nuanced challenges experienced by young adults with T1D, the individual skills developed in response to their mental health challenges and the ways that this understanding can shape future programming to support mental health, quality of life and well-being. The ongoing involvement of the PAC as co-researchers underscores the enduring impact of patient engagement in developing integrated care solutions.

PATIENT OR PUBLIC CONTRIBUTION

The co-design of the TECC-T1D3 model was enriched by the invaluable contributions of individuals with lived experience. This included the engagement of a diverse PAC in the recruitment of participants in co-design interviews and co-design events. PAC members actively participated in research decision-making with their insights informing a robust recruitment strategy. Beyond recruitment, PAC members continue to serve as co-researchers, shaping ongoing research and actively contributing to the TECC-T1D3 project. Six PAC members are co-authors on this manuscript.

From pediatric to adult care: a survey on the transition process in type 1 diabetes mellitus and the diabetes services in Italy

AIMS

The present study assessed the transitioning process of young adults with type 1 diabetes mellitus (T1D) in Italy.

MATERIALS AND METHODS

We asked Pediatric Diabetes Centers (PDC) and Adult Diabetes Centers (CAD) to fill in a web-based survey on the current state of services, the number of transitioning adolescents with T1D within the last year, observations on limitations, and future directions.

RESULTS

93 centers (46 PDCs, 47 CADs) joined the study. The total number of subjects with T1D being followed by a PDC was 16,261 (13,779 minors and 2483 young adults), while CADs had 25,500 patients. The survey showed an uneven situation. Only some services had a dedicated diabetes team (78% of PDCs, 64% of CADs). 72% of PDCs and 58% of CADs reported a protocol dedicated to transition. The median age for transition was 19 (range 16-25 years); the time required for preparing transition, indicated by both PDCs and CADs, was 5.5 months. A high percentage of CADs (80%) confirmed receiving sufficient clinical information, mainly through paper or computerized reports. The transition process is hampered by a lack of resources, logistical facilities, and communication between services. While some services have a protocol, monitoring of results is only carried out in a few cases. Most specialists expressed the need to enhance integration and continuity of treatment.

CONCLUSIONS

The current situation could be improved. Applying standard guidelines, taking into consideration both clinicians' and patients' necessities, would lead to a more successful transition process.

Changes in health-related quality of life during transition to adult healthcare: an international prospective cohort study

OBJECTIVE

To study changes in health-related quality of life (HRQoL) in adolescents and young adults (AYAs) with chronic medical conditions across the transfer to adult healthcare and associations of HRQoL with transition readiness and experience of care.

METHODS

Participants in this international (Finland, Australia) prospective cohort study were recruited in the year prior to transfer to adult health services and studied 12 months later. In addition to two HRQoL scales (Pediatric Quality of Life inventory (PedsQL), 16D), the Am I ON TRAC for Adult Care Questionnaire and Adolescent Friendly Hospital Survey measured transition readiness and experience of care and categorised by quartile. Data were compared before and after transfer to adult healthcare.

RESULTS

In total, 512 AYAs completed the first survey (0-12 months before transfer of care) and 336 AYAs completed it 1 year later (retention rate 66%, mean ages 17.8 and 18.9 years, respectively). Mean total PedsQL scores (76.5 vs 78.3) showed no significant change, although the social and educational subdomains improved after transfer of care. The mean single-index 16D score remained the same, but in Finland, distress increased and the ability to interact with friends decreased after transfer. AYAs within the best quartiles of experience of care and transition readiness had better HRQoL than AYAs within the worst quartiles.

CONCLUSIONS

Overall HRQoL of AYAs remained unchanged across the transfer to adult healthcare. Recognising and supporting AYAs with unsatisfactory experience of care and poor transition readiness could improve overall HRQoL during the transition process.

TRIAL REGISTRATION NUMBER

NCT04631965.

Service use and glycaemic control of young people with type 1 diabetes transitioning from paediatric to adult care: a 5-year study

BACKGROUND

Regular contact with specialist care has been linked to better diabetes outcomes for young people with type 1 diabetes (YPwT1D), but evidence is limited to population-based service usage and outcomes.

AIMS

This observational 5-year study sought to capture YPwT1D living in the study catchment area (covering metropolitan, regional and rural Australia) as they transitioned to adult-based diabetes healthcare services and to describe their glycaemic control and complication rates, service usage and associated factors.

METHODS

Records between 2010 and 2014 in a public healthcare specialist diabetes database were extracted, care processes and outcomes were described, and associations were sought between episodes of care (EOC) and potentially predictive variables.

RESULTS

Annual cohort numbers increased yearly, but without significant differences in demographic characteristics. Each year around 40% had no reported planned specialist care, and the average number of planned EOC decreased significantly year on year. Overall, mean HbA1c levels also reduced significantly, but with higher values recorded for those living in non-metropolitan than metropolitan areas (achieving significance in 3 out of 5 years). Diabetes complication assessments were only reported in 37-46%, indicating one in five with retinopathy and hypertension affecting one in three to five young people.

CONCLUSIONS

Findings highlight the importance of investment to address the specific needs of adolescents and young adults and demonstrate the need for better support during these vulnerable early years, particularly for non-metropolitan residents. This will entail changes to funding mechanisms, the health workforce and infrastructure, and new models of care to provide equity of access and quality of specialist care.

Burnout Among Young Adults With Type 1 Diabetes

PURPOSE

The purpose of this qualitative descriptive study was to describe the experience of diabetes burnout in young adults with type 1 diabetes (T1DM). In addition, aims included participant perspectives of risk and protective factors associated with burnout and ways to balance everyday life with diabetes self-management (DSM).

METHODS

Young adults with T1DM (N = 11) were recruited through social media platforms and modified snowball sampling and interviewed. Informational redundancy was achieved. Qualitative thematic coding and analysis were conducted within and across transcripts.

RESULTS

Diabetes burnout was described as the willingness to put diabetes and DSM on the "back burner" and let things slide due to exhaustion, frustration, apathy, and the desire to be like everyone else for a while. Risk and protective factors were identified along with strategies to achieve balance of DSM in everyday life.

CONCLUSIONS

This study identified a clear definition of diabetes burnout and acknowledges this concept as distinct and separate from other psychosocial conditions. Health care providers can utilize this information to identify individuals at risk for diabetes burnout and offer more effective support to lessen the overall burden associated with T1DM.

Efficacy of the hybrid closedloop insulin delivery system in children and adolescents with type 1 diabetes: a meta-analysis with trial sequential analysis

The aim of this study was to assess the efficacy and safety of hybrid closed-loop (HCL) systems for insulin delivery in children and adolescents with type 1 diabetes (T1D). We searched Embase, PubMed, and Cochrane Library for randomized controlled trials (RCTs) published until March 2023 comparing the HCL therapy with control therapies for children and adolescents with T1D. We computed weighted mean differences (WMDs) for continuous outcomes and risk ratios (RRs) with 95% confidence intervals (CIs) for binary endpoints. Four RCTs and 501 patients were included, of whom 323 were randomized to HCL therapy. Compared with control therapies, HCL significantly improved the period during which glucose level was 70-180 mg/dL (WMD 10.89%, 95% CI 8.22-13.56%) and the number of participants with glycated hemoglobin (HbA1c) level < 7% (RR 2.61, 95% CI 1.29-5.28). Also, HCL significantly reduced the time during which glucoselevel was > 180 mg/dL (WMD-10.46%, 95% CI-13.99 to-6.93%) and the mean levels of glucose (WMD-16.67 mg/dL, 95% CI-22.25 to-11.09 mg/dL) and HbA1c (WMD-0.50%, 95% CI-0.68 to-0.31). There were no significant differences between therapies regarding time during which glucose level was < 70 mg/dL or <54 mg/dL or number of episodes of ketoacidosis, hyperglycemia, and hypoglycemia. In this meta-analysis, HCL compared with control therapies was associated with improved time in range and HbA1c control in children and adolescents with T1D and a similar profile of side effects. These findings support the efficacy of HCL in the treatment of T1D in this population.

Health-related quality of life and self-reported health status in adolescents with chronic health conditions before transfer of care to adult health care: an international cohort study

BACKGROUND

Heath-related quality of life (HRQoL) is lower in adolescents with chronic health conditions compared to healthy peers. While there is evidence of some differences according to the underlying condition and gender, differences by measure and country are poorly understood. In this study we focus on the differences in HRQoL in adolescents with various chronic medical conditions in the year before transfer of care to adult health services. We also study the associations of two different HRQoL measurements to each other and to self-reported health.

METHODS

We recruited 538 adolescents from New Children`s Hospital, Helsinki, Finland, and the Royal Children`s Hospital, Melbourne, Australia in 2017-2020. We used two validated HRQoL measurement instruments, Pediatric Quality of Life Inventory (PedsQL) and 16D, and a visual analog scale (VAS) for self-reported health status.

RESULTS

In total, 512 adolescents (50.4% female, mean age 17.8 [SD 1.2] years), completed the survey measures. Higher HRQoL was reported in males than females in both countries (PedsQL 79.4 vs. 74.1; 16D 0.888 vs. 0.846), and in adolescents from Finland than Australia (80.6 vs. 72.2 and 0.905 vs. 0.825, p < 0.001 for all). Adolescents with diabetes, rheumatological, nephrological conditions and/or organ transplants had higher HRQoL than adolescents with neurological conditions or other disease syndromes (p < 0.001). PedsQL and 16D scores showed a strong correlation to each other (Spearman correlation coefficient r = 0.81). Using the 7-point VAS (1-7), 52% (248 of 479) considered their health status to be good (6-7) and 10% (48 of 479) rated it poor (1-2). Better self-reported health was associated with higher HRQoL.

CONCLUSIONS

The HRQoL of transition aged adolescents varies between genders, diagnostic groups, and countries of residence. The association between self-reported health and HRQoL suggests that brief assessment using the VAS could identify adolescents who may benefit from in-depth HRQoL evaluation.

TRIAL REGISTRATION

Trial registration name The Bridge and registration number NCT04631965 ( https://clinicaltrials.gov/ct2/show/NCT04631965 ).

Young Adults with Type 1 Diabetes

Young adults experience multiple developmental transitions across social, educational, vocational, residential, and financial life domains. These transitions are potential competing priorities to managing a chronic condition such as type 1 diabetes and can contribute to poor psychosocial and medical outcomes. In this narrative review, we describe population outcomes of young adult populations and the unique considerations associated with managing type 1 diabetes in young adulthood. We provide an overview of the current evidence-based strategies to improve care for young adults with type 1 diabetes and recommendations for future directions in the field.

Determinants of adherence to insulin and blood glucose monitoring among adolescents and young adults with type 1 diabetes in Qatar: a qualitative study

Background

Adherence to insulin and blood glucose monitoring (BGM) is insufficient in adolescents and young adults (AYAs) with type 1 diabetes (T1D) worldwide and in Qatar. Little is known about the factors related to being aware of suboptimal adherence and the beliefs related to suboptimal adherence in this group. This qualitative study investigated factors related to awareness of, and beliefs about suboptimal adherence, as well as the existence of specific action plans to combat suboptimal adherence using the I-Change model.

Methods

The target group was comprised of 20 Arab AYAs (17-24 years of age) with T1D living in Qatar. Participants were interviewed via semi-structured, face-to-face individual interviews, which were audio-recorded, transcribed verbatim, and analyzed using the Framework Method.

Results

Suboptimal adherence to insulin, and particularly to BGM, in AYAs with T1D was identified. Some AYAs reported to have little awareness about the consequences of their suboptimal adherence and how this can adversely affect optimal diabetes management. Participants also associated various disadvantages to adherence ( e.g., hypoglycemia, pain, among others) and reported low self-efficacy in being adherent ( e.g., when outside home, in a bad mood, among others). Additionally, goal setting and action-planning often appeared to be lacking. Factors facilitating adherence were receiving support from family and healthcare providers, being motivated, and high self-efficacy.

Conclusions

Interventions that increase awareness concerning the risks of suboptimal adherence of AYAs with T1D are needed, that increase motivation to adhere by stressing the advantages, creating support and increasing self-efficacy, and that address action planning and goal parameters.

Overcoming Barriers to Diabetes Management in Young Adults with Type 1 Diabetes by Leveraging Telehealth: A Pilot Study

OBJECTIVE

The LIFT-YA (leveraging intensive follow-up treatment in young adults) quality improvement program was developed to address clinical and social barriers in young adults (YA) with type 1 diabetes (T1D), using telehealth visits to promote clinic attendance and improve diabetes care.

METHODS

LIFT-YA enrolled YA aged 18-30 with T1D and HbA1c >8% (64 mmol/mol) who had established adult care in our diabetes clinic. The 6-month, 7-visit hybrid program was facilitated by a case manager serving as the liaison between participants and the care team. The primary end-points were within-group and between-group changes from the baseline in HbA1c at the last visit and adoption of continuous glucose monitoring (CGM).

RESULTS

Of the 57 eligible YA, 24 were enrolled and 33 were unable to participate (UTP). Thirteen of the enrolled participants attended at least 4/7 visits ("completers", C), whereas 11 were noncompleters (NC). HbA1c at the end of the program was significantly lower in the C versus UTP group [median -1.0; IQR (-0.6, -2.5) vs -0.25 (0.2, -1.0) in UTP; P < .05]. The percentage of CGM users significantly increased by 70% in the C group (P < .05), but did not change in the NC and UTP groups. Limited access to telehealth and the high cost of frequent visits were the main hurdles preventing enrollment into or completion of the program.

CONCLUSIONS

The LIFT-YA pathway was associated with a significant HbA1c reduction and an increase in the adoption of CGM. Policy changes are necessary to expand access to LIFT-YA and other programs for high-risk YA with T1D in underserved communities and across all backgrounds.

Lifestyle in Emerging Adults with Type 1 Diabetes Mellitus: A Qualitative Systematic Review

Emerging adulthood is a transitional stage with significant lifestyle changes, making it especially challenging for those living with type 1 diabetes mellitus. This systematic review synthesizes qualitative research to explore how emerging adulthood (18-29 years) influences lifestyle behaviors in individuals with type 1 diabetes mellitus. CINAHL, Cochrane Library, Global Health, Nursing & Allied Health Premium, PsycINFO, PubMed, Scopus, and WOS were searched for original qualitative studies addressing the lifestyle of 18-31-year-olds with type 1 diabetes mellitus, published between January 2010 and March 2021 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Thirty-five studies met the inclusion criteria and their findings were categorized into eight topics (emotions and feelings, nutrition, perceptions, risky behaviors, self-care, sleep, social relationships, and stigma) using meta-aggregation, as outlined in the Joanna Briggs Institute Manual for Evidence Synthesis. The spontaneity characteristic of emerging adulthood can undermine self-care. This is because new environments, schedules, and relationships encountered during this life stage often lead to the neglect of diabetes management, owing to the various social, academic, and occupational demands. This review highlights the necessity of creating health promotion strategies tailored to the unique lifestyle aspects of emerging adults with type 1 diabetes mellitus.

Research design and baseline participant characteristics of the Resilient, Empowered, Active Living with Diabetes - Telehealth (REAL-T) Study: A randomized controlled trial for young adults with type 1 diabetes

BACKGROUND

Type 1 diabetes (T1D) is a chronic condition affecting nearly 1.9 million people in the United States. Young adults (YAs) with T1D face unique challenges in managing their condition, experiencing poorer health and well-being than other age groups. The current study is evaluating the Resilient, Empowered, Active Living (REAL) intervention, previously shown to improve glucose levels and quality of life among YAs with diabetes, using telehealth delivery (REAL-T) to expand reach and accessibility. This paper reports on the methodology and baseline participant characteristics of the REAL-T study.

METHODS

REAL-T is a two-arm randomized controlled trial that recruited 18-30 year olds with T1D via clinics and social media advertising. Data collection, which was adapted to be fully remote due to COVID-19, occurs every three months for one year. Participants receive either usual care or a 6-month telehealth occupational therapy intervention. The primary outcome is glycated hemoglobin (A1c); secondary outcomes include diabetes distress, quality of life, and continuous glucose monitor-derived measures.

RESULTS

The study enrolled a diverse sample of 209 YAs with T1D. Analysis of baseline data indicates equivalence between the intervention and control groups. Study participants have notably higher diabetes distress and poorer mental well-being than similar populations.

CONCLUSION

The REAL-T study successfully adapted to remote implementation during the COVID-19 pandemic. By examining long-term outcomes, mediating pathways, and cost-effectiveness, the study will contribute knowledge of the impact of tailored interventions for YAs with T1D, designed to reduce disparities and improve health and well-being in this population.

The Impact of Modern Anti-Diabetic Treatment on Endothelial Progenitor Cells

Diabetes is one of the leading chronic diseases globally with a significant impact on mortality. This condition is associated with chronic microvascular and macrovascular complications caused by vascular damage. Recently, endothelial progenitor cells (EPCs) raised interest due to their regenerative properties. EPCs are mononuclear cells that are derived from different tissues. Circulating EPCs contribute to regenerating the vessel's intima and restoring vascular function. The ability of EPCs to repair vascular damage depends on their number and functionality. Diabetic patients have a decreased circulating EPC count and impaired EPC function. This may at least partially explain the increased risk of diabetic complications, including the increased cardiovascular risk in these patients. Recent studies have confirmed that many currently available drugs with proven cardiovascular benefits have beneficial effects on EPC count and function. Among these drugs are also medications used to treat different types of diabetes. This manuscript aims to critically review currently available evidence about the ways anti-diabetic treatment affects EPC biology and to provide a broader context considering cardiovascular complications. The therapies that will be discussed include lifestyle adjustments, metformin, sulphonylureas, gut glucosidase inhibitors, thiazolidinediones, dipeptidyl peptidase 4 inhibitors, glucagon-like peptide 1 receptor analogs, sodium-glucose transporter 2 inhibitors, and insulin.

Evaluating Transition Readiness in Older Adolescents and Young Adults With Type 1 Diabetes

For older adolescents and young adults (AYAs) with type 1 diabetes, successful transition from pediatric to adult diabetes care requires ongoing planning and support. Yet, the transition to adult care is not always smooth. Some AYAs struggle to leave pediatric care or experience significant gaps between pediatric and adult diabetes care. The use of diabetes-specific transition readiness assessments can inform transition planning and support successful preparation for adult care. This study evaluated transition readiness in a diverse sample of AYAs nearing transition to adult diabetes care. Findings suggest that AYAs may benefit from additional preparation and education related to sexual health, tobacco use, and diabetes complications.

Romantic Relationships Among Emerging Adults With and Without Type 1 Diabetes

We compared the romantic relationships of emerging adults with type 1 diabetes to those without type 1 diabetes. We examined whether there were group differences in romantic relationships and relationship quality and whether aspects of romantic relationships were connected to psychological and diabetes health. Emerging adults (mean age 27 years) with (n = 88) and without (n = 99) type 1 diabetes took part in the study. Participants completed an online questionnaire that assessed romantic relationships, psychological health, and diabetes health. Results showed that males with type 1 diabetes were significantly less likely than males without diabetes and either group of females to be involved in a romantic relationship. Among those in a relationship, there were no group differences in relationship quality. For both groups, being in a relationship was associated with less loneliness and greater life satisfaction. Among those in a romantic relationship, the quality of the relationship was more strongly related to psychological outcomes for those with than for those without diabetes. There was modest evidence that relationship quality was linked to better diabetes outcomes. When partner supportive and unsupportive diabetes interactions were examined, there was more evidence that unsupportive interactions were harmful (i.e., related to worse psychological and diabetes outcomes) than there was evidence that supportive interactions were beneficial. These findings underscore the importance of romantic relationships for health among emerging adults in general and suggest that there may be an even greater impact for those with type 1 diabetes.

Associations of Diabetes-related and Health-related Quality of Life With Glycemic Levels in Adolescents With Type 1 Diabetes Preparing to Transition to Adult Care

OBJECTIVES

As adolescents with type 1 diabetes (T1D) progress to adulthood, they assume responsibility for diabetes self-management while dealing with competing life demands, decreasing parental support, and the transfer to adult care. Lower perceived quality of life (QOL) may hamper diabetes management, which is associated with suboptimal glycemic levels. Our objective was to determine associations of diabetes- and health-related QOL with glycemic management (glycated hemoglobin [A1C]) in adolescents with T1D before their transfer to adult care.

METHODS

We conducted a cross-sectional analysis of baseline data from the Group Education Trial to Improve Transition (GET-IT- T1D) in adolescents with T1D (16 to 17 years of age). Participants completed validated questionnaires measuring diabetes-related QOL (PedsQL 3.2 Diabetes Module) and health-related QOL (PedsQL 4.0 Generic Core Scales). Associations of QOL Total and subscale scores with A1C were assessed using linear regression models adjusted for sex, diabetes duration, socioeconomic status, insulin pump use, and mental health comorbidity.

RESULTS

One hundred fifty-three adolescents with T1D were included (mean age, 16.5 [standard deviation, 0.3] years). Diabetes-related QOL Total scores (adjusted β=-0.04; 95% confidence interval [CI], -0.05 to -0.02) as well as subscale scores for Diabetes Symptoms (adjusted β=-0.02; 95% CI, -0.04 to -0.00) and Diabetes Management (adjusted β=-0.04; 95% CI, -0.05 to -0.02) were inversely associated with A1C. Health-related QOL Total scores were not associated with A1C, but Psychosocial Health subscale scores were (adjusted β=-0.01; 95% CI, -0.03 to -0.00).

CONCLUSION

Our results suggest that strategies focussing on diabetes-related QOL and psychosocial health may help prepare adolescents for the increasing responsibility of diabetes self-care.

Executive Functioning, Daily Self-Regulation, and Diabetes Management while Transitioning into Emerging Adulthood

BACKGROUND

Executive functioning (EF) predicts better Type 1 diabetes (T1D) management in the high-risk years after high school, but the daily self-regulation processes involved are unclear.

PURPOSE

To examine whether EF is associated with daily self-regulation that minimizes one's exposure or buffers adverse reactions to daily diabetes problems, and to determine whether these patterns become stronger during the transition out of high school.

METHODS

A measurement burst design with convenience sampling was used. Seniors in high school with T1D (N = 207; 66% female) completed self-report (i.e., Behavioral Rating Inventory of Executive Functioning) and performance measures of EF (i.e., Delis-Kaplan Executive Function System). A 14-day daily diary assessing self-regulation failures, diabetes problems, affect, and indicators of diabetes management was completed at baseline and 1 year later.

RESULTS

Correlations and multilevel modeling were conducted. Lower self-reported EF problems were associated with lower average levels of daily self-regulation failures, and these variables were associated with fewer daily diabetes problems. In contrast, better EF performance was unrelated to average daily self-regulation failures, and was unexpectedly associated with more frequent diabetes problems in year 2. Equally across years, on days participants reported lower than their average levels of daily self-regulation failures, they had fewer diabetes problems, regardless of EF. On days with lower than average diabetes problems, participants reported better diabetes management indicators. EF generally did not buffer daily associations in either year.

CONCLUSIONS

Regardless of EF, promoting daily self-regulation may prevent diabetes problems and promote T1D management in daily life at this high-risk transitional time.

Narrowing the Divide: The Role of Telehealth in Type 1 Diabetes Care for Marginalized Communities

Widespread uptake of telehealth in response to the COVID-19 pandemic has highlighted geographic, demographic, and economic disparities in access to virtual care. However, research studies and clinical programs that predate the pandemic demonstrate the potential for telehealth-based interventions to improve access to and outcomes of type 1 diabetes (T1D) care for individuals in geographically or socially marginalized communities. In this expert commentary, we discuss telehealth-based care models that have been successful in improving care for marginalized T1D populations. We also outline the policy changes needed to expand access to such interventions to reduce established disparities in T1D care and promote better health equity among people living with T1D.

Greater Telehealth Use Results in Increased Visit Frequency and Lower Physician Related-Distress in Adolescents and Young Adults With Type 1 Diabetes

BACKGROUND

Type one diabetes (T1D) management is challenging for adolescents and young adults (AYAs) due to physiological changes, psychosocial challenges, and increasing independence, resulting in increased diabetes distress and hemoglobin A1c (HbA1c). Alternative care models that engage AYAs and improve diabetes-related health outcomes are needed.

METHODS

A 15-month study evaluated an adaptation of the Colorado Young Adults with T1D (CoYoT1) Care model. CoYoT1 Care includes person-centered care, virtual peer groups, and physician training delivered via telehealth. AYAs (aged 16-25 years) were partially randomized to CoYoT1 or standard care, delivered via telehealth or in-person. As the study was ending, the COVID-19 pandemic forced all AYAs to transition to primarily telehealth appointments. This secondary analysis compares changes in clinic attendance, T1D-related distress, HbA1c, and device use between those who attended more than 50% of diabetes clinic visits via telehealth and those who attended more sessions in-person throughout the course of the study.

RESULTS

Out of 68 AYA participants, individuals (n = 39, 57%) who attended most (>50%) study visits by telehealth completed more diabetes care visits (3.3 visits) than those (n = 29, 43%) who primarily attended visits in-person (2.5 visits; P = .007). AYAs who primarily attended visits via telehealth maintained stable physician-related distress, while those who attended more in-person visits reported increases in physician-related distress (P = .03).

CONCLUSIONS

Greater usage of telehealth improved AYA engagement with their care, resulting in increased clinic attendance and reduced physician-related diabetes distress. A person-centered care model delivered via telehealth effectively meets the needs of AYAs with T1D.

Indicators of Healthcare Transition Progress Among College Youth With Type 1 Diabetes

OBJECTIVE

Adolescents with chronic diseases must navigate changing healthcare needs in college and beyond. This study examined the ability of college youth with type 1 diabetes (T1D) to achieve transition milestones and ascertained sociodemographic predictors of a successful healthcare transition (HCT).

METHODS

College youth with T1D were recruited via social media and direct outreach to participate in a web-based study, during which they answered questions about the HCT process. Descriptive statistics and multivariable regression were used to evaluate HCT measures as a function of sociodemographic variables.

RESULTS

Nearly two-thirds of participants (N = 138) had discussions with their providers about changing healthcare needs (65.9%) and transferring care to adult physicians (64.5%); less than one-third (27.9%) discussed obtaining health insurance as an adult. Females were more likely than males to discuss transitioning to adult providers (70.3% vs 40.7%, P < .01). Those covered on a parent's insurance (vs other) plan were more likely to receive help with finding adult providers (79.3% vs 44.4%, P = .04) but less likely to discuss how to obtain health insurance (25.0% vs 61.1%, P < .01). These differences persisted after adjustment.

CONCLUSIONS

Improvement is needed with regard to college youth with T1D becoming autonomous managers of their own care. Gaps were found in their experiences of discussing changing healthcare needs, locating adult providers, and obtaining health insurance-especially among those who were younger, male, and not covered under parental insurance. Efforts to improve the HCT process should focus particularly on these subgroups to advance healthcare delivery in this population.

The Therapeutic Potential of Mesenchymal Stem Cells in the Treatment of Diabetes Mellitus

Mesenchymal stem cells (MSCs) exist in many tissues and can differentiate into cells of multiple lineages, such as adipocytes, osteoblasts, or chondrocytes. MSC administration has demonstrated therapeutic potential in various degenerative and inflammatory diseases (e.g., graft-vs.-host disease, multiple sclerosis, Crohn's disease, organ fibrosis, and diabetes mellitus [DM]). The mechanisms involved in the therapeutic effects of MSCs are multifaceted. Generally, implanted MSCs can migrate to sites of injury, where they establish an anti-inflammatory and regenerative microenvironment in damaged tissues. In addition, MSCs can modulate innate and adaptive immune responses through immunosuppressive mechanisms that involve immune cells, inflammatory cytokines, chemokines, and immunomodulatory factors. DM has a high prevalence worldwide; it also contributes to a high rate of mortality worldwide. MSCs offer a promising therapeutic agent to prevent or repair damage from DM and diabetic complications through properties such as multilineage differentiation, homing, promotion of angiogenesis, and immunomodulation (e.g., prevention of oxidative stress, fibrosis, and cell death). In this study, we review current findings regarding the immunomodulatory and regenerative mechanisms of MSCs, as well as their therapeutic applications in DM and DM-related complications.

"Fear That One Day I May Not Be Able to Afford Insulin": The Emotional Burden of Diabetes Costs During Emerging Adulthood

Emerging adults (EAs) with type 1 diabetes (T1D) often experience challenges in diabetes management, in particular transitioning to financial independence. EAs 18-30 years of age with T1D completed online surveys about diabetes distress and an open-ended query about the most important worry among survey questions. Most of the 287 respondents (89.5%) endorsed "Agree" or "Somewhat agree" to the statement "I worry about the cost of diabetes." Responses did not differ by gender, age, diabetes duration, race/ethnicity, diabetes technology use, student status, income, or insurance status. However, a greater proportion of those not endorsing cost as a substantial burden achieved A1c <7% (92.9%) versus those who were neutral (46.2%) or who endorsed cost as a burden (50.6%) (P = 0.004). Furthermore, in open-ended responses, cost was the most frequently noted worry. Diabetes costs are a major concern for EAs, likely contributing to diabetes distress during this developmental stage, and clinicians should consider discussing diabetes costs with this population.

Relationship Between Moderate-to-Vigorous Physical Activity and Glycemia Among Young Adults with Type 1 Diabetes and Overweight or Obesity: Results from the Advancing Care for Type 1 Diabetes and Obesity Network (ACT1ON) Study

Aims: Using data from the ACT1ON study, we conducted secondary analyses to assess the relationship between minutes of moderate-to-vigorous physical activity (MVPA) and glycemia in adults with type 1 diabetes (T1D) and overweight or obesity. Materials and Methods: Participants (n = 66) with T1D provided measures of glycemia (hemoglobin A1c [HbA1c], percent of time below range <70 mg/dL, time-in-range [TIR 70-180 mg/dL], and time above range [TAR >180 mg/dL]) and self-reported physical activity (Global Physical Activity Questionnaire [GPAQ] and Previous Day Physical Activity Recalls [PDPAR]) at baseline, 3, 6, and 9 months postintervention. Wearable activity data were available for a subset of participants (n = 27). Associations were estimated using mixed effects regression models adjusted for design, demographic, clinical, and dietary covariates. Results: Among young adults 19-30 years of age with a baseline HbA1c of 7.9% ± 1.4% and body mass index of 30.3 (interquartile range 27.9, 33.8), greater habitual weekly MVPA minutes were associated with higher HbA1c through the GPAQ (P < 0.01) and wearable activity data (P = 0.01). We did not observe a significant association between habitual MVPA and any continuous glucose monitoring metrics. Using PDPAR data, however, we observed that greater daily MVPA minutes were associated with more TAR (P < 0.01) and reduced TIR (P < 0.01) on the day following reported physical activity. Conclusions: Among young adults with T1D and overweight or obesity, increased MVPA was associated with worsened glycemia. As physical activity is vital to cardiovascular health and weight management, additional research is needed to determine how to best support young adults with T1D and overweight or obesity in their efforts to increase physical activity. Clinical Trial Registration number: NCT03651622.

Diabetes Distress in Emerging Adulthood: Content Validity of the Problem Areas in Diabetes-Emerging Adult Version (PAID-EA) Using Qualitative Analysis

PURPOSE

The purpose of this study was to explore the emotional work of diabetes during emerging adulthood and to explicate the validity of a newly developed measure of diabetes distress (DD) for use with emerging adults living with type 1 diabetes mellitus (T1DM), the Problem Areas in Diabetes-Emerging Adult version (PAID-EA).

METHODS

Young people ages 18 to 30 with T1DM were recruited online to complete a cross-sectional survey including measures of DD, depressive symptomology, and the PAID-EA. To evaluate content validity, 2 open-ended questions asked what was the most significant emotion or worry discussed in the survey items and what feelings were missed in those items. Responses were analyzed using directed qualitative content analysis.

RESULTS

A total of 254 (87%) participants responded to at least 1 of the 2 open-ended questions. Three themes and 1 subtheme were identified: (1) fear of the future with the subtheme of worry about the cost of diabetes, (2) acute worries about living with diabetes, and (3) challenges with finding support. More PAID-EA items corresponded with these themes than items on the original Problem Areas in Diabetes or Center for Epidemiologic Studies Depression Scale, supporting the validity of the PAID-EA and clarifying the developmental-stage-specific aspects of DD.

CONCLUSIONS

Emerging adulthood is a period in which the future should hold infinite possibility, but young people with T1DM describe a staggering fear of the future with markedly limited possibilities, supporting the need to measure the developmental-stage-specific experience of DD as captured on the PAID-EA.

Suboptimal glycemic control in adolescents and young adults with type 1 diabetes from 2011 to 2020 across Australia and New Zealand: Data from the Australasian Diabetes Data Network registry

BACKGROUND

Competing challenges in adolescence and young adulthood can distract from optimal type 1 diabetes (T1D) self-management, and increase risks of premature morbidity and mortality. There are limited data mapping the glycemic control of people with T1D in this age group, across Australasia.

RESEARCH DESIGN AND METHODS

Clinical data were extracted from the Australasian Diabetes Data Network, a prospective clinical diabetes registry. Inclusion criteria were individuals with T1D aged 16-25 years at their last recorded T1D healthcare visit (from 1st January 2011 to 31st December 2020), with T1D duration of at least 1 year. Data were stratified by two last recorded T1D healthcare visit ranges, while generalized estimated equation (GEE) modeling was used to examine factors associated with HbA1c across visits during the 10 year period.

RESULTS

Data from 6329 young people (52.6% male) attending 24 diabetes centers across Australasia were included. At the last visit within the most recent 5 years, mean ± SD age was 18.5 ± 2.3 years, T1D duration was 8.8 ± 4.7 years and HbA1c was 8.8 ± 1.8% (72.2 ± 19.9 mmol/mol); only 12.3% had an HbA1c below the international target of <7.0% (53 mmol/mol). Across all T1D healthcare visits, in GEE modeling, higher HbA1c was associated with female sex (B = 0.20; 95% CI 0.12 to 0.29, p < 0.001), longer T1D duration (B = 0.04, 0.03 to 0.05, p < 0.001). Lower HbA1c was associated with attendance at a pediatric T1D healthcare setting (B = -0.33, -0.45 to -0.21, p < 0.001) and use of CSII versus BD/MDI therapy (B = -0.49, -0.59 to 0.40, p < 0.001).

CONCLUSIONS

This Australasian study demonstrates widespread and persistent sub-optimal glycemic control in young people with T1D, highlighting the urgent need to better understand how healthcare services can support improved glycemic control in this population.

Determinants of healthful eating and physical activity among adolescents and young adults with type 1 diabetes in Qatar: A qualitative study

BACKGROUND

In Qatar, as in the rest of the world, the sharp rise in the prevalence of type 1 diabetes (T1D) is a leading cause for concern, in terms associated with morbidity, mortality, and increasing health costs. Besides adhering to medication, the outcome of diabetes management is also dependent on patient adherence to the variable self-care behaviors including healthful eating (HE) and physical activity (PA). Yet, dietary intake and PA in adolescents and young adults (AYAs) with T1D are known to fall short of recommended guidelines. The aim of this study was to develop an in-depth understanding of the behavioral determinants of HE and PA adherence among Arab AYAs within the age range of 17-24 years with T1D attending Hamad General Hospital.

METHODS

Semi-structured, face-to-face individual interviews were conducted with 20 participants. Interviews were based on an integrative health behavior change model, the I-Change model (ICM). All interviews were audio-recorded, transcribed verbatim, and analyzed using the framework method.

RESULTS

More participants reported non-adherence than adherence. Several motivational determinants of adherence to HE and PA were identified. The majority of participants were cognizant of their own behaviors towards HE and PA. Yet, some did not link low adherence to HE and PA with increased risks of health problems resulting from T1D. Facilitators to adherence were identified as being convinced of the advantages of HE and PA, having support and high self-efficacy, a high level of intention, and a good health care system.

CONCLUSION

The suboptimal adherence in AYAs to HE and PA needs more attention. Supportive actions are needed to encourage adherence to a healthy lifestyle to achieve benefits in terms of glycemic control and overall health outcomes, with a special focus on adolescents. Interventions are needed to foster motivation by addressing the relevant determinants in order to promote adherence to these two behaviors in AYAs with T1D.

14-Year Longitudinal Trajectories of Depressive Symptoms Among Youth With and Without Type 1 Diabetes

OBJECTIVE

There is evidence that youth with type 1 diabetes are at risk for depression, and depression is a significant risk factor for subsequent psychological and physical health problems. However, it is not clear if/when this depression risk emerges. The goal of this study was to determine if there are differences in levels of depressive symptoms between youth with and without type 1 diabetes that develop over the course of emerging adulthood. We also examined whether adolescent psychosocial variables predicted depressive symptoms during emerging adulthood.

METHODS

Youth with (n = 132) and without (n = 131) type 1 diabetes were enrolled in the study at average age 12 and followed for 14 years. Depressive symptoms were measured throughout the study. Psychosocial variables of interest were measured during adolescence.

RESULTS

Group differences in depressive symptoms emerged by study end at average age 26. Depressive symptoms appeared to decline over time for youth without diabetes and to increase over time for youth with diabetes. Parent relationship difficulties increased over adolescence as did peer conflict for the entire cohort. Supportive relationships with parent and peers predicted fewer end of study depressive symptoms (controlling for baseline depressive symptoms)-equally so for both groups.

CONCLUSIONS

This study provides evidence that those with type 1 diabetes may be at risk for depressive symptoms many years after diagnosis and after adolescence. Although relational difficulties with parents and peers increase during adolescence, supportive relationships over the course of adolescence may help to mitigate depressive symptoms during young adulthood.

Protocol for a feasibility study and process evaluation of a psychosocially modelled diabetes education programme for young people with type 1 diabetes: the Youth Empowerment Skills (YES) programme

INTRODUCTION

Adolescence is a challenging period for young people with type 1 diabetes, associated with worsening glycaemia and care disengagement. Educational interventions in this period tend to focus on diabetes-specific skills, with less emphasis on the psychosocial challenges associated with diabetes experienced by young people. To address this limitation, we codesigned with young people a psychosocially modelled programme of diabetes education, named 'Youth Empowerment Skills' (YES). The programme aims to facilitate a positive adaptation to life with diabetes and engagement with diabetes care through peer-based learning, immersive simulations and support from an outreach youth worker. Here, we present a protocol for a feasibility study of the YES programme.

METHODS AND ANALYSIS

The study was designed following the Medical Research Council Complex Intervention Evaluation Framework to: test the feasibility (acceptance, implementability, recruitment and completion) of the YES programme; and estimate its efficacy in relation to metabolic and psychosocial outcomes. The study will take place in diabetes centres serving socioculturally diverse populations. We will conduct a feasibility randomised controlled trial (waiting-list design) with integrated process evaluation. Fifty young people with type 1 diabetes (aged 14-19 years) will be randomly allocated to either the YES intervention or a waiting-list control. Randomisation acceptability will be assessed with provision for a preference allocation. Outcomes will be evaluated at 6 months, at which point the waiting list participants will be exposed to the YES programme with further follow-up to 12 months. A simultaneous process evaluation will use a mixed-methods approach collecting qualitative and quantitative data. Study findings will be used to optimise the intervention components, outcome measures and recruitment methods to inform a subsequent definitive trial.

ETHICS AND DISSEMINATION

The protocol has ethical approval from the UK Health Research Authority (approval IRAS project ID: 279877). Findings will be disseminated in multiple formats for lay and professional audiences.

PROTOCOL DATE AND VERSION

7 April 2021, V.1.1.

TRIAL REGISTRATION NUMBER

NCT04670198.

The association between pediatric mental health disorders and type 1 diabetes-related outcomes

OBJECTIVE

Transition from pediatric to adult healthcare systems is a difficult process for young adults with Type 1 Diabetes (T1D) and most patients experience a deterioration in disease control. Mental health (MH) disorders are common in individuals with T1D and are believed to play a role in disease control and transition of care. We evaluated the association between the presence of pediatric MH disorder and measures of success in diabetes care in young adults who recently transitioned to adult care.

RESEARCH DESIGN AND METHODS

Retrospective cohort study of young adults in a large adult endocrinology system who transitioned from a pediatric hospital system after 2009. MH disorders were diagnosed by clinical pediatric psychologists during routine care at the pediatric hospital. Measurements of Hemoglobin A1c, diabetes-related emergencies, clinic attendance and intervals in transition were assessed and compared between the pediatric and adult hospital systems.

RESULTS

237 young adults were identified and 100 (42%) of these were diagnosed with a MH disorder during pediatric care. Presence of a MH disorder was associated with higher Hemoglobin A1c levels prior to transition and increased rates of diabetes-related hospitalizations during the transition interval. Patients with a MH disorder were less likely to establish a pattern of consistent follow up after transition (p = 0.021).

CONCLUSIONS

MH disorders are common and predict greater challenges with diabetes management and less effective transition into the adult endocrinology system. Early recognition of MH disorders may allow for allocation of more proactive and intensive support for affected patients.

Socio-cognitive determinants affecting insulin adherence/non-adherence in late adolescents and young adults with type 1 diabetes: a systematic review protocol

Objective

This systematic review aims to investigate the key socio-cognitive determinants associated with adherence/non-adherence to insulin treatment in late adolescents and young adults in the age range of 17–24 years with T1D.

Methods

A pre-specified search strategy will be used to search for studies in the electronic databases and citation indexes: PubMed, EMBASE, Web of Science, and PsycINFO. Two researchers will screen the title and the abstract independently, then will read and critically appraise the full text of each included study. A third independent reviewer will resolve disagreements in data extraction until consensus. Data will be extracted using the Population, Exposure, Outcomes, Study characteristics framework. Study selection will follow the updated guideline for reporting systematic reviews (PRISMA 2020) and will take place from 15 October 2021 to 1 January 2022. The methodological quality and risk of bias of the observational studies will be assessed by the JBI Critical Appraisal Checklist for Cohort and JBI Critical Appraisal Checklist for Analytical Cross Sectional Studies.

Results

A qualitative narrative synthesis will present the characteristics and the quality of studies and the outcomes of concern.

Conclusion

Based on the contemporary literature, this review will synthesize the evidence on the socio-cognitive determinants associated with adherence/non-adherence to insulin treatment in late adolescents and young adults in the age range of 17–24 years with T1D. The findings will help design patient-centered interventions to promote adherence to insulin in this age group, guide patients’ consultations and diabetes self-management education (DSME) programs.

Protocol registration: PROSPERO ID: CRD42021233074.

Living with type 1 diabetes mellitus in emerging adulthood: A qualitative study

OBJECTIVE

Few studies have investigated the impact of diabetes considering its effects on developmental tasks that are typical of emerging adulthood. The present study aimed to investigate how emerging adults with a chronic condition such as type 1 diabetes mellitus manage with this developmental phase.

METHODS

30 emerging adults diagnosed with diabetes (18-34 years, females = 19) took part in an autobiographical interview investigating their experience of dealing with type 1 diabetes. Narratives were analysed by means of a qualitative thematic analysis of an inductive type.

RESULTS

Thematic analysis pointed out five thematic areas strictly related to the tasks of emerging adulthood: the development of intimate relationships, university life, work and plans for the future, the achievement of individual autonomy, the construction of an adult identity and family planning. Every thematic area reported a number of subthemes related to specific difficulties experienced by participants in reaching their developmental tasks due to chronic disease. Emerged themes considered both negative and positive outcomes of living with type 1 diabetes mellitus in emerging adulthood, such as a personal growth related to identity development.

CONCLUSION

The authors discussed results considering complexities and resources associated with diabetes in the light of developmental tasks of emerging adulthood.

Limited surgery and conformal photon radiation therapy for pediatric craniopharyngioma: long-term results from the RT1 protocol

BACKGROUND

Our aim was to estimate long-term disease control and complications after conformal radiation therapy (CRT) in children and adolescents with craniopharyngioma.

MATERIALS AND METHODS

Pediatric patients with craniopharyngioma (n = 101) were enrolled on or treated according to a phase II single institutional protocol from 1998. Surgery was individualized, and CRT (54Gy) was administered using a 1.0 cm or 0.5 cm clinical target volume margin. Patients were followed for 10 years by serial MR imaging and MR angiography and a battery of tests to measure the effects of treatment.

RESULTS

Twenty patients had tumor progression. Twelve patients who had tumor progression died due to tumor (n = 6) or complications related to tumor or treatment (n = 6). With a median follow-up of 14.94 years for survivors, the 10 year estimates (±SE) of progression-free survival (PFS), event-free survival (EFS), and overall survival (OS) were 78.84% ± 4.10%, 77.12% ± 4.19%, and 96.02% ± 1.95%, respectively. OS, EFS, and PFS were significantly associated with race, shunt status, and tumor volume. The 10 year cumulative incidence (±SE) of the secondary tumor (1.99% ± 1.40%), secondary malignant tumor (1.0% ± 1.0%), necrosis (1.98% ± 1.39%), vasculopathy (8.47% ± 2.90%), and permanent neurologic deficits (8.28% ± 3.37%) were estimated by competing risk analysis. Three patients required revascularization surgery. Salvage therapy was successful in 13 patients using surgery and radiosurgery.

CONCLUSIONS

Limited surgery and CRT using photons results in excellent tumor control. Tumor control and the incidence and severity of complications are associated with host, tumor, and treatment factors.

Toward a better understanding of transition from paediatric to adult care in type 1 diabetes: A qualitative study of adolescents

AIMS

Type 1 diabetes is associated with significant morbidity, with an increasing risk of acute diabetes-related complications in adolescence and emerging adulthood. Purposeful transition from paediatric to adult-oriented care could mitigate this risk but is often lacking. Detailed understanding of the perspectives of adolescents in their final year of paediatric care is essential to inform delivery of transition care programs.

METHODS

We conducted semi-structured interviews with adolescents (aged 17 years) with type 1 diabetes at an academic institution from April 2017 to May 2018. Participants were recruited through convenience sampling. Sixty-one interviews were transcribed for analysis. Coding followed the principles of thematic analysis.

RESULTS

Thirty-six percent of participants were male, and participants were from diverse socioeconomic backgrounds. We found three overarching themes in our analysis: first, difficulties navigating changing relationships with parents and healthcare teams; second, the need to increase type 1 diabetes self-management and differing comfort levels based on age of diagnosis; and third, perceived responsibilities for transition care preparation (for both the paediatric team and adolescents themselves) focused not only on type 1 diabetes-specific skills but also on healthcare system structures.

CONCLUSIONS

Our findings suggest that novel transition programs addressing changing inter-personal relationships, disease-specific self-management (adapted for age of diagnosis), and healthcare system navigation, supported by parents and peers, may be needed to improve transition care for adolescents with type 1 diabetes.

Needs of young adults with type 1 diabetes during life transitions - An Australian-Danish experience

OBJECTIVE

To explore the similarities and differences in the needs of young adults with T1D during life transitions.

METHODS

Data obtained for this paper was based on three qualitative studies carried out in Denmark and Australia. In total, 33 Individual interviews and two focus groups (n = 46) were conducted. Data was analysed using thematic analysis.

RESULTS

The most pertinent themes related to the importance of support from peers with diabetes and healthcare professionals to help young adults adjust to independent living. The main difference experienced by Australian and Danish young adults related to the willingness and barriers in clinical attendance during this transitional period.

CONCLUSIONS

Clinical care for young adults with diabetes can be better adapted to support this population as they transition through significant milestones by engagement on the young adults' terms and encouraging young adults to seek out peer support. It is vital that clinical care is tailored to support them in order to ensure the best transition into adulthood with diabetes.

PRACTICE IMPLICATIONS

Clinicians need to adopt a person-centred approach when engaging with young adults with diabetes. Considerations need to be made around external factors related to life events in young adulthood that may influence diabetes care.