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Zhou W, Zhu R, Qu A. Estimating Optimal Infinite Horizon Dynamic Treatment Regimes via pT-Learning. J Am Stat Assoc 2022. [DOI: 10.1080/01621459.2022.2138760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Wenzhuo Zhou
- Department of Statistics, University of California Irvine, Irvine, CA;
| | - Ruoqing Zhu
- Department of Statistics, University of Illinois Urbana-Champaign, Champaign, IL;
| | - Annie Qu
- Department of Statistics, University of California Irvine, Irvine, CA,
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Corbin KD, Igudesman D, Addala A, Casu A, Crandell J, Kosorok MR, Maahs DM, Pokaprakarn T, Pratley RE, Souris KJ, Thomas J, Zaharieva DP, Mayer-Davis E. Design of the advancing care for type 1 diabetes and obesity network energy metabolism and sequential multiple assignment randomized trial nutrition pilot studies: An integrated approach to develop weight management solutions for individuals with type 1 diabetes. Contemp Clin Trials 2022; 117:106765. [PMID: 35460915 DOI: 10.1016/j.cct.2022.106765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 03/07/2022] [Accepted: 04/14/2022] [Indexed: 11/30/2022]
Abstract
Young adults with type 1 diabetes (T1D) often have difficulty co-managing weight and glycemia. The prevalence of overweight and obesity among individuals with T1D now parallels that of the general population and contributes to dyslipidemia, insulin resistance, and risk for cardiovascular disease. There is a compelling need to develop a program of research designed to optimize two key outcomes-weight management and glycemia-and to address the underlying metabolic processes and behavioral challenges unique to people with T1D. For an intervention addressing these dual outcomes to be effective, it must be appropriate to the unique metabolic phenotype of T1D, and to biological and behavioral responses to glycemia (including hypoglycemia) that relate to weight management. The intervention must also be safe, feasible, and accepted by young adults with T1D. In 2015, we established a consortium called ACT1ON: Advancing Care for Type 1 Diabetes and Obesity Network, a transdisciplinary team of scientists at multiple institutions. The ACT1ON consortium designed a multi-phase study which, in parallel, evaluated the mechanistic aspects of the unique metabolism and energy requirements of individuals with T1D, alongside a rigorous adaptive behavioral intervention to simultaneously facilitate weight management while optimizing glycemia. This manuscript describes the design of our integrative study-comprised of an inpatient mechanistic phase and an outpatient behavioral phase-to generate metabolic, behavioral, feasibility, and acceptability data to support a future, fully powered sequential, multiple assignment, randomized trial to evaluate the best approaches to prevent and treat obesity while co-managing glycemia in people with T1D. Clinicaltrials.gov identifiers: NCT03651622 and NCT03379792. The present study references can be found here: https://clinicaltrials.gov/ct2/show/NCT03651622 https://clinicaltrials.gov/ct2/show/NCT03379792?term=NCT03379792&draw=2&rank=1 Submission Category: "Study Design, Statistical Design, Study Protocols".
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Affiliation(s)
- Karen D Corbin
- AdventHealth, Translational Research Institute, Orlando, FL, United States of America
| | - Daria Igudesman
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America; School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Ananta Addala
- Stanford Diabetes Research Center and Health Research and Policy (Epidemiology), Stanford, CA, United States of America; Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Anna Casu
- AdventHealth, Translational Research Institute, Orlando, FL, United States of America
| | - Jamie Crandell
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Michael R Kosorok
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - David M Maahs
- Stanford Diabetes Research Center and Health Research and Policy (Epidemiology), Stanford, CA, United States of America; Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Teeranan Pokaprakarn
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Richard E Pratley
- AdventHealth, Translational Research Institute, Orlando, FL, United States of America
| | - Katherine J Souris
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America; School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Joan Thomas
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America; School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Dessi P Zaharieva
- Stanford Diabetes Research Center and Health Research and Policy (Epidemiology), Stanford, CA, United States of America; Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Elizabeth Mayer-Davis
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America; School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America.
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Ray MK, McMichael A, Rivera-Santana M, Noel J, Hershey T. Technological Ecological Momentary Assessment Tools to Study Type 1 Diabetes in Youth: Viewpoint of Methodologies. JMIR Diabetes 2021; 6:e27027. [PMID: 34081017 PMCID: PMC8212634 DOI: 10.2196/27027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 03/26/2021] [Accepted: 04/03/2021] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Mary Katherine Ray
- Department of Psychiatry, Washington University in St. Louis, St. Louis, MO, United States
| | - Alana McMichael
- Department of Psychiatry, Washington University in St. Louis, St. Louis, MO, United States
| | - Maria Rivera-Santana
- Department of Psychiatry, Washington University in St. Louis, St. Louis, MO, United States
| | - Jacob Noel
- Department of Psychiatry, Washington University in St. Louis, St. Louis, MO, United States
| | - Tamara Hershey
- Department of Psychiatry, Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, MO, United States
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Abstract
The vision for precision medicine is to use individual patient characteristics to inform a personalized treatment plan that leads to the best possible health-care for each patient. Mobile technologies have an important role to play in this vision as they offer a means to monitor a patient's health status in real-time and subsequently to deliver interventions if, when, and in the dose that they are needed. Dynamic treatment regimes formalize individualized treatment plans as sequences of decision rules, one per stage of clinical intervention, that map current patient information to a recommended treatment. However, most existing methods for estimating optimal dynamic treatment regimes are designed for a small number of fixed decision points occurring on a coarse time-scale. We propose a new reinforcement learning method for estimating an optimal treatment regime that is applicable to data collected using mobile technologies in an out-patient setting. The proposed method accommodates an indefinite time horizon and minute-by-minute decision making that are common in mobile health applications. We show that the proposed estimators are consistent and asymptotically normal under mild conditions. The proposed methods are applied to estimate an optimal dynamic treatment regime for controlling blood glucose levels in patients with type 1 diabetes.
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Affiliation(s)
- Daniel J Luckett
- Department of Biostatistics, University of North Carolina at Chapel Hill
| | - Eric B Laber
- Department of Statistics, North Carolina State University
| | - Anna R Kahkoska
- Department of Nutrition, University of North Carolina at Chapel Hill
| | | | | | - Michael R Kosorok
- Department of Biostatistics, University of North Carolina at Chapel Hill
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Affiliation(s)
- Rayhan A. Lal
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
- Division of Endocrinology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Bruce Buckingham
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - David M. Maahs
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
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Zhong VW, Crandell JL, Shay CM, Gordon-Larsen P, Cole SR, Juhaeri J, Kahkoska AR, Maahs DM, Seid M, Forlenza GP, Mayer-Davis EJ. Dietary intake and risk of non-severe hypoglycemia in adolescents with type 1 diabetes. J Diabetes Complications 2017; 31:1340-1347. [PMID: 28476567 PMCID: PMC5526710 DOI: 10.1016/j.jdiacomp.2017.04.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 03/29/2017] [Accepted: 04/16/2017] [Indexed: 12/12/2022]
Abstract
AIMS To determine the association between dietary intake and risk of non-severe hypoglycemia in adolescents with type 1 diabetes. METHODS Type 1 adolescents from a randomized trial wore a blinded continuous glucose monitoring (CGM) system at baseline for one week in free-living conditions. Dietary intake was calculated as the average from two 24-h dietary recalls. Non-severe hypoglycemia was defined as having blood glucose <70mg/dL for ≥10min but not requiring external assistance, categorized as daytime and nocturnal (11PM-7AM). Data were analyzed using logistic regression models. RESULTS Among 98 participants with 14,277h of CGM data, 70 had daytime hypoglycemia, 66 had nocturnal hypoglycemia, 55 had both, and 17 had neither. Soluble fiber and protein intake were positively associated with both daytime and nocturnal hypoglycemia. Glycemic index, monounsaturated fat, and polyunsaturated fat were negatively associated with daytime hypoglycemia only. Adjusting for total daily insulin dose per kilogram eliminated all associations. CONCLUSIONS Dietary intake was differentially associated with daytime and nocturnal hypoglycemia. Over 80% of type 1 adolescents had hypoglycemia in a week, which may be attributed to the mismatch between optimal insulin dose needed for each meal and actually delivered insulin dose without considering quality of carbohydrate and nutrients beyond carbohydrate. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01286350.
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Affiliation(s)
- Victor W Zhong
- Department of Nutrition, University of North Carolina, Chapel Hill, NC, USA
| | - Jamie L Crandell
- School of Nursing and Department of Biostatistics, University of North Carolina, Chapel Hill, NC, USA
| | - Christina M Shay
- Center for Health Metrics and Evaluation, the American Heart Association, Dallas, TX, USA
| | - Penny Gordon-Larsen
- Department of Nutrition, University of North Carolina, Chapel Hill, NC, USA; Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Stephen R Cole
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Juhaeri Juhaeri
- Global Pharmacovigilance and Epidemiology, Sanofi, Bridgewater, NJ, USA
| | - Anna R Kahkoska
- Department of Nutrition, University of North Carolina, Chapel Hill, NC, USA
| | - David M Maahs
- Lucile Packard Children's Hospital and Stanford University Medical Center, Stanford University, Palo Alto, CA, USA
| | - Michael Seid
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Gregory P Forlenza
- Barbara Davis Center for Childhood Diabetes, University of Colorado, Aurora, CO, USA
| | - Elizabeth J Mayer-Davis
- Department of Nutrition, University of North Carolina, Chapel Hill, NC, USA; Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA.
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Dadlani V, Levine JA, McCrady-Spitzer SK, Dassau E, Kudva YC. Physical Activity Capture Technology With Potential for Incorporation Into Closed-Loop Control for Type 1 Diabetes. J Diabetes Sci Technol 2015; 9:1208-16. [PMID: 26481641 PMCID: PMC4667300 DOI: 10.1177/1932296815609949] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Physical activity is an important determinant of glucose variability in type 1 diabetes (T1D). It has been incorporated as a nonglucose input into closed-loop control (CLC) protocols for T1D during the last 4 years mainly by 3 research groups in single center based controlled clinical trials involving a maximum of 18 subjects in any 1 study. Although physical activity data capture may have clinical benefit in patients with T1D by impacting cardiovascular fitness and optimal body weight achievement and maintenance, limited number of such studies have been conducted to date. Clinical trial registries provide information about a single small sample size 2 center prospective study incorporating physical activity data input to modulate closed-loop control in T1D that are seeking to build on prior studies. We expect an increase in such studies especially since the NIH has expanded support of this type of research with additional grants starting in the second half of 2015. Studies (1) involving patients with other disorders that have lasted 12 weeks or longer and tracked physical activity and (2) including both aerobic and resistance activity may offer insights about the user experience and device optimization even as single input CLC heads into real-world clinical trials over the next few years and nonglucose input is introduced as the next advance.
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Affiliation(s)
- Vikash Dadlani
- Endocrine Research Unit, Mayo Clinic, Rochester, MN, USA
| | - James A Levine
- Mayo Clinic, Scottsdale, AZ, USA Obesity Solutions, Mayo Clinic Arizona and Arizona State University, Tempe, AZ, USA
| | | | - Eyal Dassau
- Harvard John A. Paulson School of Engineering and Applied Sciences, Cambridge, MA, USA
| | - Yogish C Kudva
- Endocrine Research Unit, Mayo Clinic, Rochester, MN, USA
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Ayano-Takahara S, Ikeda K, Fujimoto S, Asai K, Oguri Y, Harashima SI, Tsuji H, Shide K, Inagaki N. Carbohydrate intake is associated with time spent in the euglycemic range in patients with type 1 diabetes. J Diabetes Investig 2015; 6:678-86. [PMID: 26543542 PMCID: PMC4627545 DOI: 10.1111/jdi.12360] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 03/11/2015] [Accepted: 03/31/2015] [Indexed: 01/14/2023] Open
Abstract
AIMS/INTRODUCTION Greater glycemic variability and lack of predictability are important issues for patients with type 1 diabetes. Dietary factors are one of the contributors to this variability, but how closely diet is linked to glycemic fluctuation on a daily basis has not been investigated. We examined the association between carbohydrate intake and glycemic excursion in outpatients. MATERIALS AND METHODS A total of 33 patients with type 1 diabetes were included in the analyses (age 44.5 ± 14.7 years, diabetes duration 15.1 ± 8.3 years, 64% female, 30% using insulin pump, glycated hemoglobin 8.1 ± 1.3%). Time spent in euglycemia (70-180 mg/dL), hyperglycemia (>180 mg/dL) and hypoglycemia (<70 mg/dL) of consecutive 48-h periods of continuous glucose monitoring data were collected together with simultaneous records of dietary intake, insulin dose and physical activity. Correlation analyses and multiple regression analyses were used to evaluate the contribution of carbohydrate intake to time spent in the target glycemic range. RESULTS In multiple regression analyses, carbohydrate intake (β = 0.53, P = 0.001), basal insulin dose per kg per day (β = -0.31, P = 0.034) and diabetes duration (β = 0.30, P = 0.042) were independent predictors of time spent in euglycemia. Carbohydrate intake (β = -0.51, P = 0.001) and insulin pump use (β = -0.34, P = 0.024) were independent predictors of time spent in hyperglycemia. Insulin pump use (β = 0.52, P < 0.001) and bolus insulin dose per kg per day (β = 0.46, P = 0.001) were independent predictors of time spent in hypoglycemia. CONCLUSIONS Carbohydrate intake is associated with time spent in euglycemia in patients with type 1 diabetes.
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Affiliation(s)
- Shiho Ayano-Takahara
- Department of Diabetes, Endocrinology and Nutrition, Graduate School of Medicine, Kyoto University Kyoto, Japan
| | - Kaori Ikeda
- Department of Diabetes, Endocrinology and Nutrition, Graduate School of Medicine, Kyoto University Kyoto, Japan
| | - Shimpei Fujimoto
- Department of Diabetes, Endocrinology and Nutrition, Graduate School of Medicine, Kyoto University Kyoto, Japan ; Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kochi University Kochi, Japan
| | - Kanae Asai
- Department of Metabolism and Clinical Nutrition, Kyoto University Hospital Kyoto, Japan
| | - Yasuo Oguri
- Department of Diabetes, Endocrinology and Nutrition, Graduate School of Medicine, Kyoto University Kyoto, Japan
| | - Shin-Ichi Harashima
- Department of Diabetes, Endocrinology and Nutrition, Graduate School of Medicine, Kyoto University Kyoto, Japan
| | - Hidemi Tsuji
- Department of Metabolism and Clinical Nutrition, Kyoto University Hospital Kyoto, Japan
| | - Kenichiro Shide
- Department of Metabolism and Clinical Nutrition, Kyoto University Hospital Kyoto, Japan
| | - Nobuya Inagaki
- Department of Diabetes, Endocrinology and Nutrition, Graduate School of Medicine, Kyoto University Kyoto, Japan
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Liu SW, Huang HP, Lin CH, Chien IL. Modified control algorithms for patients with type 1 diabetes mellitus undergoing exercise. J Taiwan Inst Chem Eng 2014. [DOI: 10.1016/j.jtice.2014.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Rasbach LE, Atkins AE, Milaszewski KM, Keady J, Schmidt LM, Volkening LK, Laffel LM. Treatment recommendations following 3-day masked continuous glucose monitoring (CGM) in youth with type 1 diabetes. J Diabetes Sci Technol 2014; 8:494-7. [PMID: 24876612 PMCID: PMC4455435 DOI: 10.1177/1932296814528135] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Glycemic control remains suboptimal in youth with type 1 diabetes. Retrospective continuous glucose monitoring (CGM) has demonstrated utility in fine-tuning diabetes management by detecting postprandial hyperglycemia and hypoglycemia. In this study, we explored the process of 3-day masked CGM use, subsequent treatment recommendations, and impact on A1c in a clinic-based sample of youth with type 1 diabetes. Over 2 years, 122 youth were referred for masked CGM. Patients/families completed a diary of blood glucose levels, insulin doses, food intake, and exercise during CGM use. A1c was assessed pre- and 2-3 months post-CGM. Treatment recommendations were formulated using data from CGM reports and diaries. Mean age was 14.3 ± 3.9 years, diabetes duration was 7.5 ± 4.7 years, and A1c was 8.5 ± 1.1% (69 ± 12 mmol/mol); 61% were pump-treated. Patients received an average of 3.1 ± 1.1 treatment recommendations following review of the CGM report. Most (80%) received reinforcement of the importance of preprandial bolusing; 37% received a recommendation regarding advanced insulin management (use of combination boluses/attend to active insulin). Receipt of the latter recommendation was related to A1c improvement ≥0.5% (OR: 4.0, P < .001). Masked CGM offers opportunities to guide advanced insulin management (by injection or pump), which may yield A1c improvements in youth with type 1 diabetes.
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Affiliation(s)
- Lisa E Rasbach
- Pediatric, Adolescent, and Young Adult Section, Genetics and Epidemiology Section, Joslin Diabetes Center, Boston, MA, 2. Medical University of South Carolina College of Nursing, Charleston, SC, USA
| | - Ashley E Atkins
- Pediatric, Adolescent, and Young Adult Section, Genetics and Epidemiology Section, Joslin Diabetes Center, Boston, MA, USA
| | - Kerry M Milaszewski
- Pediatric, Adolescent, and Young Adult Section, Genetics and Epidemiology Section, Joslin Diabetes Center, Boston, MA, USA
| | - Joyce Keady
- Pediatric, Adolescent, and Young Adult Section, Genetics and Epidemiology Section, Joslin Diabetes Center, Boston, MA, USA
| | - Lisa M Schmidt
- Pediatric, Adolescent, and Young Adult Section, Genetics and Epidemiology Section, Joslin Diabetes Center, Boston, MA, USA
| | - Lisa K Volkening
- Pediatric, Adolescent, and Young Adult Section, Genetics and Epidemiology Section, Joslin Diabetes Center, Boston, MA, USA
| | - Lori M Laffel
- Pediatric, Adolescent, and Young Adult Section, Genetics and Epidemiology Section, Joslin Diabetes Center, Boston, MA, USA
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Abstract
Pursuit of a closed-loop artificial pancreas that automatically controls the blood glucose of individuals with type 1 diabetes has intensified during the past six years. Here we discuss the recent progress and challenges in the major steps towards a closed-loop system. Continuous insulin infusion pumps have been widely available for over two decades, but "smart pump" technology has made the devices easier to use and more powerful. Continuous glucose monitoring (CGM) technology has improved and the devices are more widely available. A number of approaches are currently under study for fully closed-loop systems; most manipulate only insulin, while others manipulate insulin and glucagon. Algorithms include on-off (for prevention of overnight hypoglycemia), proportional-integral-derivative (PID), model predictive control (MPC) and fuzzy logic based learning control. Meals cause a major "disturbance" to blood glucose, and we discuss techniques that our group has developed to predict when a meal is likely to be consumed and its effect. We further examine both physiology and device-related challenges, including insulin infusion set failure and sensor signal attenuation. Finally, we discuss the next steps required to make a closed-loop artificial pancreas a commercial reality.
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