Cognition and Type 1 Diabetes in Children and Adolescents

Assessing Dynamic Cognitive Function in the Daily Lives of Youths With and Without Type 1 Diabetes: Usability Study

Background

Studies have shown a relationship between worse glycemic control and lower cognitive scores in youths with type 1 diabetes (T1D). However, most studies assess long-term glucose control (eg, years-decades) and cognition at a single time point. Understanding this relationship at a higher temporal resolution (eg, minutes-hours) and in naturalistic settings has potential clinical implications. Newer technology (eg, continuous glucose monitoring [CGM] and ecological momentary assessment) provides a unique opportunity to explore the glucose dynamics that influence dynamic cognition; that is, cognitive functions that fluctuate short-term and are influenced by environmental factors.

Objective

Before we can assess this relationship, we need to determine the feasibility of measuring cognition in youths in daily life and determine the plausibility of obtaining glucose variation with CGM to be integrated with real-time cognition measures. This study's purpose was to assess the acceptability of measuring dynamic cognition using a smartphone app and adherence to cognitive testing in daily life in youths with and without T1D. Further, we assessed CGM-derived glucose measures at temporally related timeframes to cognitive testing in naturalistic settings.

Methods

Data were obtained from 3 studies including one in-laboratory study and 2 remote studies. For all studies, youths were asked to complete cognitive tests on the Ambulatory Research in Cognition (ARC) smartphone app that measured processing speed, associative memory, and working memory. For the in-laboratory study, youths completed testing 4 times during 1 session. For the remote studies, youths were asked to complete cognitive tests 5 times per day for either 10 or 14 consecutive days in daily life. Youths were asked to rate their impressions of the app. Youths with T1D wore a CGM.

Results

74 youths (n=53 control; n=21 T1D) aged 4-16 years participated. Youths generally reported liking or understanding the ARC app tasks in a laboratory and remote setting. Youths had high testing adherence in daily life (2350/3080 to 721/900, 76.3%-80.2%) and none dropped out. The percentage of measurements within each glycemic range taken immediately before the app's cognitive testing was 3% (28/942) low glucose, 51% (484/942) euglycemia, 23% (221/942) high glucose, and 22% (210/942) very high glucose. In the 2-hour window before each cognitive task, mean glucose was 182.5 (SD 76.2) mg/dL, SD in glucose was 27.1 mg/dL (SD 18.7), and the mean maximum difference between the highest and lowest glucose was 85.5 (SD 53.7) mg/dL.

Conclusions

The results suggest that using the ARC smartphone app to assess dynamic cognitive functions in youths with and without T1D is feasible. Further, we showed CGM-derived glycemic variability at temporally associated timeframes of dynamic cognitive assessments. The next steps include using ecological momentary assessment in a fully powered study to determine the relationship between short-term glycemic control and cognition in youths with T1D.

Cognitive Function in Early Onset Type 1 Diabetes in Children

OBJECTIVES

To assess cognitive function and factors affecting it in Indian children with early-onset type 1 diabetes (T1D) (less than 6 y).

METHODS

This cross-sectional, single-centre study recruited children diagnosed with T1D before 6 y of age and having a disease duration of at least 2 y, as cases. Controls were age- and sex-matched apparently healthy children or siblings. Children with birth asphyxia, intellectual disability, syndromic children, or pre-existing psychiatric illness were excluded. Enrolled children underwent cognitive assessment using Malin's Intelligence Scale for Indian Children (MISIC), and scores in various subtests were compared between cases and controls.

RESULTS

A total of 60 children were enrolled in each group. When compared to controls, cases had significantly lower scores on most subtests, verbal, performance and overall Intelligence Quotient (IQ- 100.62 ± 3.26 vs. 103.23 ± 1.22). HbA1c >9%, severe hypoglycemia and lesser duration since the last diabetic ketoacidosis (DKA) episode significantly correlated with lower neurocognitive scores.

CONCLUSIONS

Children with early onset T1D showed significant deficits in various cognitive domains and IQ. Poor glycemic control, higher glycemic variability and exposure to severe hypoglycemia are risk factors for poor cognitive outcomes in these children. Further longitudinal studies could potentially aid in a finer understanding of factors affecting cognitive functioning in T1D children in developing countries.

Cognitive Function during and after Pregnancy and One-Year Postpartum in Type 1 Diabetes: A Longitudinal Study

BACKGROUND

This study aims to compare the cognitive function of women with T1DM during and after pregnancy, as well as one year post-delivery. Additionally, it aims to investigate the impacts of leptin and body mass index on cognitive function.

METHODS

A prospective longitudinal cohort study was conducted involving 64 pregnant women with T1DM. Cognitive function was assessed using a cognitive assessment battery during the first trimester, immediately after delivery, and one year postpartum for the final assessment. This program evaluates a wide range of cognitive abilities and provides a comprehensive cognitive well-being score (high-moderate-low), identifying strengths and weaknesses in reasoning, memory, attention, coordination, and perception.

RESULTS

The average age of the participants was 30.9 years, with a mean diabetes duration of 14.9 years. Pregnant women with a BMI of 30 kg/m2 or higher faced an increased risk of reduced cognitive function, memory, and reasoning. Additionally, mothers with lower overall cognitive function and memory levels had significantly higher concentrations of leptin in their blood.

CONCLUSIONS

Cognitive functions-particularly reasoning and attention-are adversely affected in women with T1DM during pregnancy and shortly after delivery. Elevated BMI and leptin levels can be linked to worse cognitive outcomes in this population.

Brain functional and structural changes in diabetic children. How can intellectual development be optimized in type 1 diabetes?

The neuropsychological functioning of people with type 1 diabetes (T1D) is of key importance to the effectiveness of the therapy, which, in its complexity, requires a great deal of knowledge, attention, and commitment. Intellectual limitations make it difficult to achieve the optimal metabolic balance, and a lack of this alignment can contribute to the further deterioration of cognitive functions. The aim of this study was to provide a narrative review of the current state of knowledge regarding the influence of diabetes on brain structure and functions during childhood and also to present possible actions to optimize intellectual development in children with T1D. Scopus, PubMed, and Web of Science databases were searched for relevant literature using selected keywords. The results were summarized using a narrative synthesis. Disturbances in glucose metabolism during childhood may have a lasting negative effect on the development of the brain and related cognitive functions. To optimize intellectual development in children with diabetes, it is essential to prevent disorders of the central nervous system by maintaining peri-normal glycemic levels. Based on the performed literature review, it seems necessary to take additional actions, including repeated neuropsychological evaluation with early detection of any cognitive dysfunctions, followed by the development of individual management strategies and the training of appropriate skills, together with complex, multidirectional environmental support.

Exercise-related alterations in MCT1 and GLUT4 expressions in the liver and pancreas of rats with STZ-induced diabetes

Background

The liver and pancreas tissues play a central role in controlling glucose homeostasis. In patients with type I diabetes mellitus (T1DM), the function of these tissues is impaired. The positive effects of exercise have been shown in diabetic patients. To demonstrate the positive effects of exercise in T1DM, we examined the effects of moderate-intensity endurance training (MIET) on the liver enzymes and expression of MCT1 and GLUT4 genes.

Methods

Male Wistar rats were allocated into 4 groups of control (C), training (T), diabetic control (DC), and diabetes + training (DT). The serum levels of liver enzymes such as alanine aminotransferase (ALT), aspartate transaminase (AST), and alkaline phosphatase (ALP) were determined by ELIZA. MCT1 and GLUT4 mRNA expressions in the liver and pancreas tissues were evaluated through real-time qPCR after 10 weeks of training.

Results

The mRNA levels of MCT1 and GLUT4 decreased in DC group and increased in DT group. T1DM led to weight loss, but the weight loss was less in the DT group. T1DM caused an increase in liver enzymes such as ALT, AST and ALP, whereas endurance training preserved enzymatic levels.

Conclusion

These results suggested that MIET increases levels of MCT1 and GLUT4 liver and pancreas in the diabetic rats and improves liver function tests. Upregulation of MCT1 and GLUT4 can probably improve the function of liver and pancreas tissues and promote glucose homeostasis in T1DM.

Central nervous system microstructural alterations in Type 1 diabetes mellitus: A systematic review of diffusion Tensor imaging studies

AIMS

Type 1 diabetes mellitus (T1DM) is a chronic childhood disease with potentially persistent CNS disruptions. In this study, we aimed to systematically review diffusion tensor imaging studies in patients with T1DM to understand the microstructural effects of this entity on individuals' brains METHODS: We performed a systematic search and reviewed the studies to include the DTI studies in individuals with T1DM. The data for the relevant studies were extracted and a qualitative synthesis was performed.

RESULTS

A total of 19 studies were included, most of which showed reduced FA widespread in optic radiation, corona radiate, and corpus callosum, as well as other frontal, parietal, and temporal regions in the adult population, while most of the studies in the juvenile patients showed non-significant differences or a non-persistent pattern of changes. Also, reduced AD and MD in individuals with T1DM compared to controls and non-significant differences in RD were noted in the majority of studies. Microstructural alterations were associated with clinical profile, including age, hyperglycemia, diabetic ketoacidosis and cognitive performance.

CONCLUSION

T1DM is associated with microstructural brain alterations including reduced FA, MD, and AD in widespread brain regions, especially in association with glycemic fluctuations and in adult age.

Investigating the effects of Citrullus colocynthis on cognitive performance and anxiety-like behaviors in STZ-induced diabetic rats

Background: Diabetes can impair cognitive performance and lead to dementia. Patients with type 1 diabetes mellitus (T1DM) are reported with different levels of cognitive dysfunctions in various cognitive domains ranging from general intellectual testing to specific deficits with visuospatial abilities, motor speed, writing, attention, reading, and psychomotor efficiency. The present study aimed to investigate the effect of Citrullus colocynthis on cognitive functions.Methods: A total of 42 male Wistar rats (3-4  months old and weighing 200-250  g) were tested in the current study. Rats were randomly allocated into 3 groups of control, Diabetes, and Diabetes + Drug. The diabetic rats received Citrullus colocynthis extraction orally. The behavioral tests included the open field, elevated plus maze (EPM), novel object recognition (NOR), passive avoidance tests, and Morris Water Maze (MWM) tests. Data were analyzed using student and paired t-tests via SPSS software version 16.Results: Our results showed the protective effects of Citrullus colocynthis administration against cognitive impairments. This is followed by STZ-induced diabetes in the MWM, novel object recognition, and passive avoidance tasks. Also, it was found that Citrullus colocynthis improved anxiety in diabetic rats.Conclusion According to the findings of this study, the administration of 200  mg/kg C. colocynthis once per day for 40  days can lead to ameliorated cognitive impairments and antidiabetic effects such as increasing body weight and decreasing FBS.

Missed meal boluses and poorer glycemic control impact on neurocognitive function may be associated with white matter integrity in adolescents with type 1 diabetes

Background

The notion that pediatric type 1 diabetes impacts brain function and structure early in life is of great concern. Neurological manifestations, including neurocognitive and behavioral symptoms, may be present from childhood, initially mild and undetectable in daily life. Despite intensive management and technological therapeutic interventions, most pediatric patients do not achieve glycemic control targets for HbA1c. One of the most common causes of such poor control and frequent transient hyperglycemic episodes may be lifestyle factors, including missed meal boluses.

Objective

The aim of this study was to assess the association between specific neurocognitive accomplishments-learning and memory, inhibition ability learning, and verbal and semantic memory-during meals with and without bolusing, correlated to diffusion tensor imaging measurements of major related tracts, and glycemic control in adolescents with type 1 diabetes compared with their healthy siblings of similar age.

Study design and methods

This is a case-control study of 12- to 18-year-old patients with type 1 diabetes (N = 17, 8 male patients, diabetes duration of 6.53 ± 4.1 years) and their healthy siblings (N = 13). All were hospitalized for 30 h for continuous glucose monitoring and repeated neurocognitive tests as a function of a missed or appropriate pre-meal bolus. This situation was mimicked by controlled, patient blinded manipulation of lunch pre-meal bolus administration to enable capillary glucose level of <180 mg/dl and to >240 mg/d 2 hours after similar meals, at a similar time. The diabetes team randomly and blindly manipulated post-lunch glucose levels by subcutaneous injection of either rapid-acting insulin or 0.9% NaCl solution before lunch. A specific neurocognitive test battery was performed twice, after each manipulation, and its results were compared, along with additional neurocognitive tasks administered during hospitalization without insulin manipulation. Participants underwent brain imaging, including diffusion tensor imaging and tractography.

Results

A significant association was demonstrated between glycemic control and performance in the domains of executive functions, inhibition ability, learning and verbal memory, and semantic memory. Inhibition ability was specifically related to food management. Poorer glycemic control (>8.3%) was associated with a slower reaction time.

Conclusion

These findings highlight the potential impairment of brain networks responsible for learning, memory, and controlled reactivity to food in adolescents with type 1 diabetes whose glycemic control is poor.

Association between type 1 diabetes and neurodevelopmental disorders in children and adolescents: A systematic review and meta-analysis

Type 1 diabetes and neurodevelopmental disorders are common chronic conditions in childhood and adolescence, and having one may lead to an increased chance of developing the other. Type 1 diabetes mellitus is mainly manifested by elevated blood glucose, while neurodevelopmental diseases are composed of a variety of diseases, which are relatively complex. The purpose of this meta-analysis was to find out the prevalence of type 1 diabetes-related neurodevelopmental disorders in children and adolescents and to explore the potential association between neurodevelopmental disorders and type 1 diabetes. PubMed, Embase and Web of science databases were searched from the inception to May 22, 2022 to identify relevant studies, Finally, 24 original studies were included in the meta-analysis. Prevalence estimates for neurodevelopmental disorders in the type 1 diabetes adolescent and their 95% confidence intervals were pooled using random effects models. The pooled estimates for autism spectrum disorders (ASD) and attention deficit hyperactivity disorder (ADHD) in the type 1 diabetes population were 1.2 and 5.3%, respectively, both of which are higher than the 2019 global prevalence of ASD and ADHD in the general population. The results of the subgroup analysis showed that the prevalence of ASD and ADHD in the T1DM population tended to increase with age. In conclusion, there may be a potential link between the occurrence of type 1 diabetes mellitus and the development of neurodevelopmental disorders in children and adolescents, but more relevant studies are needed to understand the link between the underlying pathogenesis of type 1 diabetes and neurodevelopmental disorders.

Systematic review registration

[https://www.crd.york.ac.uk/PROSPERO/], identifier [CDR42022333443].

Positive Association between Preserved C-Peptide and Cognitive Function in Pregnant Women with Type-1 Diabetes

This study focused on the cognitive function of women with type 1 diabetes in pregnancy. We investigated risk factors for a low cognitive score such as age, duration of Diabetes, BMI, subclinical hypothyroidism, cardiovascular autonomic neuropathy, the impact of hypo-/hyperglycemia, and C-peptide preservation. Material and methods. Seventy-eight pregnant women with type 1 diabetes (age 31.1 ± 5.4 years, diabetes duration 14.3 ± 8.9 years) were included in the study. Cognitive function was assessed in different domains, such as reasoning, memory, attention, coordination, and perception. Results. The cognitive test values ≥400 were considered high scores, and values <400 were considered low. Relative risks for low scores for general cognitive function were associated with increased BMI > 25 kg/m2 2.208 (95% CI 1.116−4.370), HbA1c > 6.5% RR 0.774 (95% CI 0.366−1.638), subclinical hypothyroidism RR 3.111 (95% CI 1.140−8.491), and impaired cardiovascular autonomic neuropathy RR 2.250 (95% CI 1.000−5.062). Pregnant women with a lower score for general cognitive function had higher BMI and higher leptin levels. Preserved C-peptide reduces the risk for cognitive impairment (RR 0.297 (95% CI 0.097−0.912)) in pregnant women with type 1 diabetes Conclusion. BMI > 25 kg/m2, subclinical hypothyroidism, and cardiovascular autonomic neuropathy are associated with increased risk, and postprandial C-peptide preservation with reduced risk for cognitive impairment in pregnant women with type 1 diabetes.

A Pilot randomized trial to examine effects of a hybrid closed-loop insulin delivery system on neurodevelopmental and cognitive outcomes in adolescents with type 1 diabetes

Type 1 diabetes (T1D) is associated with lower scores on tests of cognitive and neuropsychological function and alterations in brain structure and function in children. This proof-of-concept pilot study (ClinicalTrials.gov Identifier NCT03428932) examined whether MRI-derived indices of brain development and function and standardized IQ scores in adolescents with T1D could be improved with better diabetes control using a hybrid closed-loop insulin delivery system. Eligibility criteria for participation in the study included age between 14 and 17 years and a diagnosis of T1D before 8 years of age. Randomization to either a hybrid closed-loop or standard diabetes care group was performed after pre-qualification, consent, enrollment, and collection of medical background information. Of 46 participants assessed for eligibility, 44 met criteria and were randomized. Two randomized participants failed to complete baseline assessments and were excluded from final analyses. Participant data were collected across five academic medical centers in the United States. Research staff scoring the cognitive assessments as well as those processing imaging data were blinded to group status though participants and their families were not. Forty-two adolescents, 21 per group, underwent cognitive assessment and multi-modal brain imaging before and after the six month study duration. HbA1c and sensor glucose downloads were obtained quarterly. Primary outcomes included metrics of gray matter (total and regional volumes, cortical surface area and thickness), white matter volume, and fractional anisotropy. Estimated power to detect the predicted treatment effect was 0.83 with two-tailed, α = 0.05. Adolescents in the hybrid closed-loop group showed significantly greater improvement in several primary outcomes indicative of neurotypical development during adolescence compared to the standard care group including cortical surface area, regional gray volumes, and fractional anisotropy. The two groups were not significantly different on total gray and white matter volumes or cortical thickness. The hybrid closed loop group also showed higher Perceptual Reasoning Index IQ scores and functional brain activity more indicative of neurotypical development relative to the standard care group (both secondary outcomes). No adverse effects associated with study participation were observed. These results suggest that alterations to the developing brain in T1D might be preventable or reversible with rigorous glucose control. Long term research in this area is needed.

Peripheral versus central insulin and leptin resistance: Role in metabolic disorders, cognition, and neuropsychiatric diseases

Insulin and leptin are classically regarded as peptide hormones that play key roles in metabolism. In actuality, they serve several functions in both the periphery and central nervous system (CNS). Likewise, insulin and leptin resistance can occur both peripherally and centrally. Metabolic disorders such as diabetes and obesity share several key features including insulin and leptin resistance. While the peripheral effects of these disorders are well-known (i.e. cardiovascular disease, hypertension, stroke, dyslipidemia, etc.), the CNS complications of leptin and insulin resistance have come into sharper focus. Both preclinical and clinical findings have indicated that insulin and leptin resistance are associated with cognitive deficits and neuropsychiatric diseases such as depression. Importantly, these studies also suggest that these deficits in neuroplasticity can be reversed by restoration of insulin and leptin sensitivity. In view of these observations, this review will describe, in detail, the peripheral and central functions of insulin and leptin and explain the role of insulin and leptin resistance in various metabolic disorders, cognition, and neuropsychiatric diseases.

Monitoring Glucose Concentrations in Children with Epilepsy on a Ketogenic Diet

Ketogenic diet (KD) and pulsatile dexamethasone therapy (PDT) are commonly used in the treatment of children with drug resistant epilepsy. Potential side effects of the KD are hypoglycemia, whereas PDT might lead to hyperglycemia. One practical option to measure glucose concentrations regularly is the flash glucose monitoring system (FGM). In this single-center study in Germany, two pediatric patients with epilepsy (age: 6.0 and 6.8 years) received FGM from the beginning of the KD over six months, in the year 2020, and one patient (9.8 years) was observed for one month on PDT and switched to the KD thereafter. Glucose concentrations were measured by using an FGM system and capillary blood measurement. Seizure frequency, changes in cognition, motor performance, social behavior, and sleep quality were evaluated. The mean hypoglycemia rate per day (65 mg/dL and lower) declined significantly in patient 1 and 2 after three months. Patient 3 showed in total seven hyperglycemic events during PDT. Patient 1 became seizure free. Improvement of attention and memory performance were reported. FGM during the KD as a treatment for drug resistant epilepsies in childhood is a practical option to explore and to avoid hypoglycemia during the KD and hyperglycemia during PDT.

Effect of ultra-rapid insulin aspart on glycemic control in children with type 1 diabetes: the experience of a Portuguese tertiary centre

Background

Postprandial hyperglycemia is one of the biggest challenges in children with type 1 diabetes (T1D). Ultra-fast-acting aspartic insulin (faster aspart) has a quicker onset of action and an earlier maximum activity. The aim of this study is to analyze the impact of faster aspart in metabolic control of pediatric patients with T1D in a “real-world” setting.

Methods

Retrospective analysis of 60 pediatric patients with T1D who changed their insulin analogue to faster aspart. Anthropometric data, insulin doses, capillary and interstitial glucose recordings and average glycated hemoglobin before and after insulin analogue’s switch were obtained. After all population analyses, patients were analyzed separately according to the type of treatment, multiple daily injections (MDI) and continuous subcutaneous insulin infusion (CSII), and according to age group.

Results

Faster aspart significantly improved metabolic control, increasing time in range (TIR) (42 vs.54%, respectively; P = 0.007) and decreasing time above range (TAR) (52 vs.40%, respectively; P = 0.009), without an increased time in hypoglycemia (7% before and after faster aspart’s introduction; P = 0.933). This was reassured in the adolescent years (n = 45), with an increase in TIR (37 vs. 47%, respectively; P = 0.034) and decrease in TAR (51 vs. 45%, respectively; P = 0.022). Patients on CSII (n = 47), also demonstrated an increase in TIR (38 vs. 50%, respectively; P = 0.010). The reduction of A1c was not statistically significant.

Conclusion

Although the advantage of faster aspart had already been demonstrated in pediatric patients under MDI, “real-world” studies, including patients under CSII, are still lacking. This study highlights the important impact of faster aspart on metabolic control in children with T1D, particularly among adolescents under CSII.

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

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

Poor glycaemic control is associated with increased risk of neurodevelopmental disorders in childhood-onset type 1 diabetes: a population-based cohort study

AIMS/HYPOTHESIS

The aim of this study was to investigate the effect of childhood-onset type 1 diabetes on the risk of subsequent neurodevelopmental disorders, and the role of glycaemic control in this association. We hypothesised that individuals with poor glycaemic control may be at a higher risk of neurodevelopmental disorders compared with the general population, as well as compared with individuals with type 1 diabetes with adequate glycaemic control.

METHODS

This Swedish population-based cohort study was conducted using data from health registers from 1973 to 2013. We identified 8430 patients with childhood-onset type 1 diabetes (diagnosed before age 18 years) with a median age of diabetes onset of 9.6 (IQR 5.9-12.9) and 84,300 reference individuals from the general population, matched for sex, birth year and birth county. Cox models were used to estimate the effect of HbA_1c on the risk of subsequent neurodevelopmental disorders, including attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorders (ASD) and intellectual disability.

RESULTS

During a median follow-up period of 5.6 years, 398 (4.7%) individuals with type 1 diabetes received a diagnosis of any neurodevelopmental disorder compared with 3066 (3.6%) in the general population, corresponding to an adjusted HR (HR_adjusted) of 1.31 (95% CI 1.18, 1.46) after additionally adjusting for other psychiatric morbidity prior to inclusion, parental psychiatric morbidity and parental highest education level. The risk of any neurodevelopmental disorder increased with HbA_1c levels and the highest risk was observed in patients with mean HbA_1c >8.6% (>70 mmol/mol) (HR_adjusted 1.90 [95% CI 1.51, 2.37]) compared with reference individuals without type 1 diabetes. In addition, when compared with patients with diabetes with HbA_1c <7.5% (<58 mmol/mol), patients with HbA_1c >8.6% (>70 mmol/mol) had the highest risk of any neurodevelopmental disorder (HR_adjusted 3.71 [95% CI 2.75, 5.02]) and of specific neurodevelopmental disorders including ADHD (HR_adjusted 4.16 [95% CI 2.92, 5.94]), ASD (HR_adjusted 2.84 [95% CI 1.52, 5.28]) and intellectual disability (HR_adjusted 3.93 [95% CI 1.38, 11.22]).

CONCLUSIONS/INTERPRETATION

Childhood-onset type 1 diabetes is associated with an increased risk of neurodevelopmental disorders, with the highest risk seen in individuals with poor glycaemic control. Routine neurodevelopmental follow-up visits should be considered in type 1 diabetes, especially in patients with poor glycaemic control.

Brain functions and cognition on transient insulin deprivation in type 1 diabetes

BACKGROUND

Type 1 diabetes (T1D) is a risk factor for dementia and structural brain changes. It remains to be determined whether transient insulin deprivation that frequently occurs in insulin-treated individuals with T1D alters brain function.

METHODS

We therefore performed functional and structural magnetic resonance imaging, magnetic resonance spectroscopy, and neuropsychological testing at baseline and following 5.4 ± 0.6 hours of insulin deprivation in 14 individuals with T1D and compared results with those from 14 age-, sex-, and BMI-matched nondiabetic (ND) participants with no interventions.

RESULTS

Insulin deprivation in T1D increased blood glucose, and β-hydroxybutyrate, while reducing bicarbonate levels. Participants with T1D showed lower baseline brain N-acetyl aspartate and myo-inositol levels but higher cortical fractional anisotropy, suggesting unhealthy neurons and brain microstructure. Although cognitive functions did not differ between participants with T1D and ND participants at baseline, significant changes in fine motor speed as well as attention and short-term memory occurred following insulin deprivation in participants with T1D. Insulin deprivation also reduced brain adenosine triphosphate levels and altered the phosphocreatine/adenosine triphosphate ratio. Baseline differences in functional connectivity in brain regions between participants with T1D and ND participants were noted, and on insulin deprivation further alterations in functional connectivity between regions, especially cortical and hippocampus-caudate regions, were observed. These alterations in functional connectivity correlated to brain metabolites and to changes in cognition.

CONCLUSION

Transient insulin deprivation therefore caused alterations in executive aspects of cognitive function concurrent with functional connectivity between memory regions and the sensory cortex. These findings have important clinical implications, as many patients with T1D inadvertently have periods of transient insulin deprivation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03392441.

FUNDING

Clinical and Translational Science Award (UL1 TR002377) from the National Center for Advancing Translational Science; NIH grants (R21 AG60139 and R01 AG62859); the Mayo Foundation.

Kolb L. An Effective Model of Diabetes Care and Education: The ADCES7 Self-Care Behaviors™

PURPOSE

The ADCES7 Self-Care Behaviors^™ (ADCES7) is a robust framework for self-management of diabetes and other related conditions, such as prediabetes and cardiometabolic diseases. It is the position of the Association of Diabetes Care and Education Specialists (ADCES) that at the cornerstone of diabetes self-management education and support, the ADCES7 is the framework for achieving behavior change that leads to effective self-management through improved behavior and clinical outcome measures. The ADCES7 model guides the health care team in effective person-centered collaboration and goal setting to achieve health-related outcomes and improved quality of life. Continued research and evidence are critical to expand this model and broaden its application to other chronic conditions. Given the advances in the science of diabetes management as well as diabetes self-management education and support, ADCES has evaluated the ADCES7 within the framework of these advances, including the digital and dynamic health care landscape.

CONCLUSION

This revised position statement blends the updates in research and ADCES's vision and expansion beyond diabetes to refresh the ADCES7 framework. This revision reflects the perspectives of all members of the health care team as they problem solve with individuals who are at risk for or who have diabetes and related conditions to achieve healthier outcomes.

Priorities in the Interdisciplinary Approach of Specific Learning Disorders (SLD) in Children with Type I Diabetes Mellitus (T1DM). From Theory to Practice

BACKGROUND

A considerable endeavor had taken place in order to understand the associated challenges for children and adolescents with Specific Learning Disorder (SLD) and Type 1 Diabetes Mellitus (T1DM) but also in order to describe the necessary skills and approaches that the care givers have to develop to assist both children and parents. (1) Aim: The aim of this review is twofold. Firstly, to highlight the T1DM's potential impact on psychological well-being, on cognitive functioning and on school performance in children and adolescents who confront SLD. Secondly, to discuss the necessity of a multidiscipline approach of poor school performance in students with SLD and T1DM, presenting the serious contribution of care providers: (a) parents/carers in the family setting, (b) teachers and psychologists in the school setting and (c) health specialists (pediatricians, nutricians, nurses, child psychiatrists and psychologists) in the medical setting. (2) Methods: In this narrative literature review of 12 selected articles, each one studies a special aspect of approach, during the diagnosis and the treatment of individuals with T1DM and SLD. The review concerns the arising problems and difficulties in the adherence to diagnosis, the management of insulin, the mental and physical wellbeing, the school performance, the cognitive functioning and learning difficulties of patients. We tried to synthesize an interdisciplinary approach that involves collaboration between family, school and medical frame; facilitating children's and adolescents' difficulties management, as well as parent and teacher involvement during the intervention implementation. (3) Results: The main issues of concern were examined through the available literature, as different factors had to be re-examined in the previous studies, regarding the potential impact of T1DM in cognitive and psychological functioning, as well as the effects of the intervention/approach/treatment of children and adolescents with SLD and T1DM. (4) Conclusions: Although T1DM diagnosis and demanding treatment are a heavy burden for children and their families, T1DM may or may not be associated with a variety of academic and psychological outcomes. Despite the variability of the reviewed research design quality, it was clearly defined that the impact of T1DM is not uniform across educational and mental variables. Strengthening the children's physical, psychological and social wellbeing is an especially important factor, as it facilitates the insulin's management as well as the learning difficulties. This is possible by supporting the parental and teacher involvement in the intervention process. This review highlights the need to reduce the distance between theory/research and practice, in some of the proposed areas in this field of knowledge.

Psychosocial morbidity among children with type-1 diabetes mellitus

Background:

Although the psychosocial impact of type-1 diabetes mellitus (T1DM) patients is well recognized, data about its prevalence in India is scant. Hence, this study was undertaken to determine the prevalence and spectrum of psychosocial morbidities among pediatric T1DM patients and factors associated with psychosocial distress.

Methods:

Among 39 pediatric T1DM patients, a cross-sectional questionnaire-based study was carried out. Psychological distress was measured by applying a childhood psychopathological measurement schedule (CPMS) questionnaire. Psychosocial distress was analyzed across various sociodemographic factors and disease-specific variables by applying the Chi-square test using the statistical package for social sciences (SPSS) version 16.

Results:

The mean age of the study sample was 11.59 + 2.65 years (range: 6–16 years). Out of a total 39 patients, 21 (53.85%) were found to be psychologically distressed. The mean CPMS score was 12.74 + 9.54. Mean scores among psychologically distressed and nondistressed patient groups were 19.19 + 8.5 and 5.22 + 2.74, respectively. Anxiety, conduct disorder, and depression were the most common problems identified. Psychosocial distress was more prevalent among those who were postpubertal, males, Muslims, residing in rural areas, living in a nuclear family, having no sibling, and from the upper-lower socioeconomic background. Psychosocial distress was significantly associated with an increased number of insulin injections per day (P = 0.041) and dietary and drug regimen noncompliance (P = 0.001).

Conclusion:

The present study revealed a very high prevalence (53.85%) of psychosocial morbidity among T1DM patients. Psychosocial distress was significantly more among patients taking an increased number of insulin injections per day and patients who were noncompliant with the dietary and drug regimen.

An Effective Model of Diabetes Care and Education: Revising the AADE7 Self-Care Behaviors®

PURPOSE

The AADE7 Self-Care Behaviors^® (AADE7) is a robust framework for self-management of diabetes and other related conditions, such as prediabetes and cardiometabolic diseases. It is the position of the American Association of Diabetes Educators (AADE) that, at the cornerstone of diabetes self-management education and support, the AADE7 is the framework for achieving behavior change that leads to effective self-management through improved behavior and clinical outcome measures. The AADE7 model guides the health care team in effective person-centered collaboration and goal setting to achieve health-related outcomes and improved quality of life. Continued research and evidence are critical to expand this model and broaden its application to other chronic conditions. Given the advances in the science of diabetes management, as well as in diabetes self-management education and support, AADE has evaluated the AADE7 within the framework of these advances, including the digital and dynamic health care landscape.

CONCLUSION

This revised position statement blends the updates in research and AADE's vision and expansion beyond diabetes to refresh the AADE7 framework. This revision reflects the perspectives of all members of the health care team as they problem solve with individuals who are at risk for or who have diabetes and related conditions to achieve healthier outcomes.

Severe Hypoglycemia: Is It Still a Threat for Children and Adolescents With Type 1 Diabetes?

Severe hypoglycemia is defined as a condition with serious cognitive dysfunction, such as a convulsion and coma, requiring external help from other persons. This condition is still lethal and is reported to be the cause of death in 4-10% in children and adolescents with type 1 diabetes. The incidence of severe hypoglycemia in the pediatric population was previously reported as high as more than 50-100 patient-years; however, there was a decline in the frequency of severe hypoglycemia during the past decades, and relationship with glycemic control became weaker than previously reported. A lot of studies have shown the neurological sequelae with severe hypoglycemia as cognitive dysfunction and abnormalities in brain structure. This serious condition also provides negative psychosocial outcomes and undesirable compensatory behaviors. Various possible factors, such as younger age, recurrent hypoglycemia, nocturnal hypoglycemia, and impaired awareness of hypoglycemia, are possible risk factors for developing severe hypoglycemia. A low HbA_1c level is not a predictable value for severe hypoglycemia. Prevention of severe hypoglycemia remains one of the most critical issues in the management of pediatric patients with type 1 diabetes. Advanced technologies, such as continuous glucose monitoring (CGM), intermittently scanned CGM, and sensor-augmented pump therapy with low-glucose suspend system, potentially minimize the occurrence of severe hypoglycemia without worsening overall glycemic control. Hybrid closed-loop system must be the most promising tool for achieving optimal glycemic control with preventing the occurrence of severe hypoglycemia in pediatric patients with type 1 diabetes.

Associations Among Taste Perception, Food Neophobia and Preferences in Type 1 Diabetes Children and Adolescents: A Cross-Sectional Study

Type 1 diabetes (T1D) is one of the most common systemic diseases in childhood which predisposes the patient to serious short-term and long-term complications, affecting all body systems. Taste and olfactory impairments were first described a long time ago in adult patients affected by diabetes (both type 1 and type 2 diabetes). However, studies evaluating taste perception, behavioral attitudes (e.g., food neophobia), and preferences toward foods in children and adolescents affected by T1D are globally lacking. Therefore, the purpose of this study was to assess taste sensitivity, food neophobia, and preferences among children and adolescents affected by T1D and healthy controls in a cross-sectional study. T1D patients presented a significantly lower ability in general to correctly identify taste qualities, especially bitter and sour tastes. Moreover, they were characterized by fewer fungiform papillae compared to controls, as well as a lower responsiveness to the bitter compound 6-n-propylthiouracil (PROP). There were no significant differences in food neophobia scores between the two groups, but differences were observed in the mean hedonic ratings for some product categories investigated. Diabetic patients showed a greater liking for certain type of foods generally characterized by sourness and bitterness, an observation probably linked to their impaired ability to perceive taste stimuli, e.g., sourness and bitterness. These results may help to enhance the understanding of these relationships in populations with elevated diet-related health risks.

Introducing a very low carbohydrate diet for a child with type 1 diabetes

Type 1 diabetes mellitus is a serious autoimmune disease for which no cure is available. The treatment includes insulin therapy, carbohydrate counting, eating healthy foods, exercising regularly, and maintaining a healthy weight. The goal is to keep blood glucose levels close to normal most of the time to delay or prevent complications. Despite the increase in the use of insulin pumps and continuous glucose monitors in recent years, the management of type 1 diabetes remains suboptimal in terms of glycaemic control and normal glycated haemoglobin (HbA1c) level. This article discusses the case of a child with type 1 diabetes who was successfully treated with a very low-carbohydrate diet, resulting in normal levels of HbA1c and normal blood glucose 95% of the time in a range of 70-180 mg/dL (4.0 mmol/L-10 mmol/L). Therefore, further studies are needed to verify how a very low carbohydrate diet impacts child development.

Impact of Early Diabetic Ketoacidosis on the Developing Brain

OBJECTIVE

This study examined whether a history of diabetic ketoacidosis (DKA) is associated with changes in longitudinal cognitive and brain development in young children with type 1 diabetes.

RESEARCH DESIGN AND METHODS

Cognitive and brain imaging data were analyzed from 144 children with type 1 diabetes, ages 4 to <10 years, who participated in an observational study of the Diabetes Research in Children Network (DirecNet). Participants were grouped according to history of DKA severity (none/mild or moderate/severe). Each participant had unsedated MRI scans and cognitive testing at baseline and 18 months.

RESULTS

In 48 of 51 subjects, the DKA event occurred at the time of onset, at an average of 2.9 years before study entry. The moderate/severe DKA group gained more total and regional white and gray matter volume over the observed 18 months compared with the none/mild group. When matched by age at time of enrollment and average HbA1c during the 18-month interval, participants who had a history of moderate/severe DKA compared with none/mild DKA were observed to have significantly lower Full Scale Intelligence Quotient scores and cognitive performance on the Detectability and Commission subtests of the Conners' Continuous Performance Test II and the Dot Locations subtest of the Children's Memory Scale.

CONCLUSIONS

A single episode of moderate/severe DKA in young children at diagnosis is associated with lower cognitive scores and altered brain growth. Further studies are needed to assess whether earlier diagnosis of type 1 diabetes and prevention of DKA may reduce the long-term effect of ketoacidosis on the developing brain.

Neurophysiological Evidence for a Compensatory Activity during a Simple Oddball Task in Adolescents with Type 1 Diabetes Mellitus

OBJECTIVE

The poor metabolic control in type 1 diabetes mellitus (T1D) has a negative impact on the developing brain. Hyperglycemia and glycemic fluctuations disrupt mainly executive functions. To assess a hypothesized deficit of the executive functions, we evaluated visual processing and reaction time in an oddball task.

METHODS

Oddball visual event-related potentials (ERPs), reaction time, and pattern-reversal visual evoked potentials (VEPs) were examined in a cohort of twenty-two 12- to 18-year-old T1D patients without diabetic retinopathy at normal glycemia and in nineteen 10- to 21-year-old healthy controls.

RESULTS

The P100 peak time of the VEPs was significantly prolonged in T1D patients compared with the control group (p < 0.017). In contrast to the deteriorated sensory response, the area under the curve of the P3b component of the ERPs was significantly larger (p = 0.035) in patients, while reaction time in the same task did not differ between groups (p = 0.713).

CONCLUSIONS

The deterioration on a sensory level, enhanced activity during cognitive processing, and balanced behavioral response support the view that neuroplasticity counterbalances the neural impairment by enhanced cognitive processing to achieve normal behavioral performance in T1D adolescents.

Functional magnetic resonance imaging reveals differences in brain activation in response to thermal stimuli in diabetic patients with and without diabetic peripheral neuropathy

Introduction

Diabetes affects both the peripheral and central nervous systems. The aim of this study was to explore the changes in brain activity in response to thermal stimuli in diabetic patients with and without diabetic peripheral neuropathy (DPN) using functional magnetic resonance imaging (fMRI).

Methods

A total of 36 right-handed volunteers were enrolled: eight patients with Type-2 diabetes mellitus and DPN, 13 patients with Type-2 diabetes mellitus lacking DPN (NDPN patients), and 15 healthy volunteers (HV). Blood oxygenation level-dependent baseline scans were performed, first without any stimuli, and then with four sessions of thermal stimuli (0, 10, 34, and 44°C, in a random order) applied to the lateral side of the right lower extremity. There was a 240-s rest interval between each thermal stimulation. Each stimulation session consisted of three cycles of 30 s of stimulation followed by 30 s of rest. After each stimuli session, the participant rated pain and itch perception on a visual analog scale. The fMRI data series were analyzed by using Statistical Parametric Mapping 8 and Data Processing Assistant for Resting-State fMRI.

Results

In response to temperature stimuli, DPN patients showed stronger activation than HV and NDPN patients, not only in brain areas that participate in somatosensory pathways (right insula, left caudate nucleus, frontal gyrus, and cingulate cortex), but also in the cognition-related cerebral areas (right temporal lobe, left hippocampus, and left fusiform gyrus). Activation of vermis 1–3 was greater in NDPN patients than in HV in response to 0°C stimulation.

Conclusions

fMRI may be useful for the early detection of central nervous system impairment caused by DPN. Our results indicate that central nervous system impairment related to diabetic neuropathy may not be limited to motion- and sensation-related cortical regions. Cognition-associated cerebral regions such as the hippocampus and fusiform gyrus are also affected by functional changes caused by DPN. This suggests that fMRI can detect the early stages of cognitive impairment in DPN patients before the symptoms become clinically significant.