Barriers and Facilitators to Uptake of Continuous Glucose Monitoring for Management of Type 2 Diabetes Mellitus in Youth

PURPOSE

The purpose of this study was to identify factors impacting the acceptability of continuous glucose monitoring (CGM) in adolescents and young adults (AYAs) with type 2 diabetes mellitus (T2DM).

METHODS

In this single-center study, semistructured interviews were conducted with AYAs with T2DM and their parents to determine attitudes about CGM, including barriers and facilitators. Interviews were audio-recorded, transcribed, and evaluated using thematic analysis.

RESULTS

Twenty AYAs and 10 parents participated (n = 30 total). AYAs were mean age 16.5 years (SD 2.2, range = 13.7-20.1) and had median diabetes duration of 1.3 years. Most were female (65%) and from minoritized background (40% non-Hispanic Black, 10% Hispanic, 5% Asian). Seven (35%) used CGM. The primary facilitator elicited was convenience over glucose meter use. Important barriers included the impact of physically wearing the device and drawing unwanted attention, desire for AYA privacy, and inadequate education about the device.

CONCLUSIONS

In this diverse sample of AYAs with T2DM and their parents, CGM was generally regarded as convenient, although concerns about worsening stigma and conflict with parents were prevalent. These findings can guide the development of patient-centered approaches to CGM for AYAs with T2DM, a critical step toward reducing inequities in diabetes technology uptake.

Understanding temporal changes and seasonal variations in glycemic trends using wearable data

Seasonal variations in glycemic trends remain largely unstudied despite the growing prevalence of diabetes. To address this gap, our objective is to investigate temporal changes in glycemic trends by analyzing intensively sampled blood glucose data from 137 patients (ages 2 to 76, primarily type 1 diabetes) over the course of 9 months to 4.5 years. From over 91,000 days of continuous glucose monitor data, we found that glycemic control decreases significantly around the holidays, with the largest decline observed on New Year's Day among the patients with already poor glycemic control (i.e., <55% time in the target range). We also observed seasonal variations in glycemic trends, with patients having worse glycemic control in the months of November to February (i.e., mid-fall and winter, in the United States), and better control in the months of April to August (i.e., mid-spring and summer). These insights are critical to inform targeted interventions that can improve diabetes outcomes.

DiaTrend: A dataset from advanced diabetes technology to enable development of novel analytic solutions

Objective digital data is scarce yet needed in many domains to enable research that can transform the standard of healthcare. While data from consumer-grade wearables and smartphones is more accessible, there is critical need for similar data from clinical-grade devices used by patients with a diagnosed condition. The prevalence of wearable medical devices in the diabetes domain sets the stage for unique research and development within this field and beyond. However, the scarcity of open-source datasets presents a major barrier to progress. To facilitate broader research on diabetes-relevant problems and accelerate development of robust computational solutions, we provide the DiaTrend dataset. The DiaTrend dataset is composed of intensive longitudinal data from wearable medical devices, including a total of 27,561 days of continuous glucose monitor data and 8,220 days of insulin pump data from 54 patients with diabetes. This dataset is useful for developing novel analytic solutions that can reduce the disease burden for people living with diabetes and increase knowledge on chronic condition management in outpatient settings.

A computational framework for discovering digital biomarkers of glycemic control

Digital biomarkers can radically transform the standard of care for chronic conditions that are complex to manage. In this work, we propose a scalable computational framework for discovering digital biomarkers of glycemic control. As a feasibility study, we leveraged over 79,000 days of digital data to define objective features, model the impact of each feature, classify glycemic control, and identify the most impactful digital biomarkers. Our research shows that glycemic control varies by age group, and was worse in the youngest population of subjects between the ages of 2–14. In addition, digital biomarkers like prior-day time above range and prior-day time in range, as well as total daily bolus and total daily basal were most predictive of impending glycemic control. With a combination of the top-ranked digital biomarkers, we achieved an average F1 score of 82.4% and 89.7% for classifying next-day glycemic control across two unique datasets.

Investigating Temporal Patterns of Glycemic Control around Holidays

Maintaining good glycemic control is a central part of diabetes care. However, it can be a tedious task because many factors in daily living can affect glycemic control. To support management, a growing number of people living with diabetes are now being prescribed continuous glucose monitors (CGMs) for real-time tracking of their blood glucose levels. However, routine use of CGMs is also an invaluable source of patient-generated data for individual and population-level studies. Prior research has shown that festive periods such as holidays can be a notable contributor to overeating and weight gain. Thus, in this work, we sought to investigate patterns of glycemic control around the holidays, particularly Thanksgiving, Christmas, and New Year, by using 3-months of CGM data from 14 patients with Type 1 Diabetes. We leveraged clinically validated metrics for quantifying glycemic control from CGM data and well-established statistical tests to compare diabetes management on holiday weeks versus non-holiday weeks. Based on our analysis, we found that 86% of subjects (12 out of 14) had worse glycemic control (i.e., more ad-verse glycemic events) during holiday weeks compared to non-holiday weeks. This general trend was prevalent amongst most subjects, however, we also observed unique individual patterns of glycemic control. Our findings provide a basis for further research on temporal patterns in diabetes management and data-driven interventions to support patients and caregivers with maintaining good glycemic control all year round.

SymptomID: A Framework for Rapid Symptom Identification in Pandemics Using News Reports

The ability to quickly learn fundamentals about a new infectious disease, such as how it is transmitted, the incubation period, and related symptoms, is crucial in any novel pandemic. For instance, rapid identification of symptoms can enable interventions for dampening the spread of the disease. Traditionally, symptoms are learned from research publications associated with clinical studies. However, clinical studies are often slow and time intensive, and hence delays can have dire consequences in a rapidly spreading pandemic like we have seen with COVID-19. In this article, we introduce SymptomID, a modular artificial intelligence–based framework for rapid identification of symptoms associated with novel pandemics using publicly available news reports. SymptomID is built using the state-of-the-art natural language processing model (Bidirectional Encoder Representations for Transformers) to extract symptoms from publicly available news reports and cluster-related symptoms together to remove redundancy. Our proposed framework requires minimal training data, because it builds on a pre-trained language model. In this study, we present a case study of SymptomID using news articles about the current COVID-19 pandemic. Our COVID-19 symptom extraction module, trained on 225 articles, achieves an F1 score of over 0.8. SymptomID can correctly identify well-established symptoms (e.g., “fever” and “cough”) and less-prevalent symptoms (e.g., “rashes,” “hair loss,” “brain fog”) associated with the novel coronavirus. We believe this framework can be extended and easily adapted in future pandemics to quickly learn relevant insights that are fundamental for understanding and combating a new infectious disease.

Establishing a Global Standard for Wearable Devices in Sport and Exercise Medicine: Perspectives from Academic and Industry Stakeholders

Millions of consumer sport and fitness wearables (CSFWs) are used worldwide, and millions of datapoints are generated by each device. Moreover, these numbers are rapidly growing, and they contain a heterogeneity of devices, data types, and contexts for data collection. Companies and consumers would benefit from guiding standards on device quality and data formats. To address this growing need, we convened a virtual panel of industry and academic stakeholders, and this manuscript summarizes the outcomes of the discussion. Our objectives were to identify (1) key facilitators of and barriers to participation by CSFW manufacturers in guiding standards and (2) stakeholder priorities. The venues were the Yale Center for Biomedical Data Science Digital Health Monthly Seminar Series (62 participants) and the New England Chapter of the American College of Sports Medicine Annual Meeting (59 participants). In the discussion, stakeholders outlined both facilitators of (e.g., commercial return on investment in device quality, lucrative research partnerships, and transparent and multilevel evaluation of device quality) and barriers (e.g., competitive advantage conflict, lack of flexibility in previously developed devices) to participation in guiding standards. There was general agreement to adopt Keadle et al.'s standard pathway for testing devices (i.e., benchtop, laboratory, field-based, implementation) without consensus on the prioritization of these steps. Overall, there was enthusiasm not to add prescriptive or regulatory steps, but instead create a networking hub that connects companies to consumers and researchers for flexible guidance navigating the heterogeneity, multi-tiered development, dynamicity, and nebulousness of the CSFW field.

Learning From the Experiences of COVID-19 Survivors: Web-Based Survey Study

Background

There are still many unanswered questions about the novel coronavirus; however, a largely underutilized source of knowledge is the millions of people who have recovered after contracting the virus. This includes a majority of undocumented cases of COVID-19, which were classified as mild or moderate and received little to no clinical care during the course of illness.

Objective

This study aims to document and glean insights from the experiences of individuals with a first-hand experience in dealing with COVID-19, especially the so-called mild-to-moderate cases that self-resolved while in isolation.

Methods

This web-based survey study called C19 Insider Scoop recruited adult participants aged 18 years or older who reside in the United States and had tested positive for COVID-19 or antibodies. Participants were recruited through various methods, including online support groups for COVID-19 survivors, advertisement in local news outlets, as well as through professional and other networks. The main outcomes measured in this study included knowledge of contraction or transmission of the virus, symptoms, and personal experiences on the road to recovery.

Results

A total of 72 participants (female, n=53; male, n=19; age range: 18-73 years; mean age: 41 [SD 14] years) from 22 US states were enrolled in this study. The top known source of how people contracted SARS-CoV-2, the virus known to cause COVID-19, was through a family or household member (26/72, 35%). This was followed by essential workers contracting the virus through the workplace (13/72, 18%). Participants reported up to 27 less-documented symptoms that they experienced during their illness, such as brain or memory fog, palpitations, ear pain or discomfort, and neurological problems. In addition, 47 of 72 (65%) participants reported that their symptoms lasted longer than the commonly cited 2-week period even for mild cases of COVID-19. The mean recovery time of the study participants was 4.5 weeks, and exactly one-half of participants (50%) still experienced lingering symptoms of COVID-19 after an average of 65 days following illness onset. Additionally, 37 (51%) participants reported that they experienced stigma associated with contracting COVID-19.

Conclusions

This study presents preliminary findings suggesting that emphasis on family or household spread of COVID-19 may be lacking and that there is a general underestimation of the recovery time even for mild cases of illness with the virus. Although a larger study is needed to validate these results, it is important to note that as more people experience COVID-19, insights from COVID-19 survivors can enable a more informed public, pave the way for others who may be affected by the virus, and guide further research.

Data-Driven Insights on Behavioral Factors that Affect Diabetes Management

The prevalence of personal health data from wearable devices enables new opportunities to understand the impact of behavioral factors on health. Unlike consumer devices that are often auxiliary, such as Fitbit and Garmin, wearable medical devices like continuous glucose monitoring (CGM) devices and insulin pumps are becoming critical in diabetes care to minimize the occurrence of adverse glycemic events. Joint analysis of CGM and insulin pump data can provide unparalleled insights on how to modify treatment regimen to improve diabetes management outcomes. In this paper, we employ a data-driven approach to study the relationship between key behavioral factors and proximal diabetic management indicators. Our dataset includes an average of 161 days of time-matched CGM and insulin pump data from 34 subjects with Type 1 Diabetes (T1D). By employing hypothesis testing and association mining, we observe that smaller meals and insulin doses are associated with better glycemic outcomes compared to larger meals and insulin doses. Meanwhile, the occurrence of interrupted sleep is associated with poorer glycemic outcomes. This paper introduces a method for inferring disrupted sleep from wearable diabetes-device data and provides a baseline for future research on sleep quality and diabetes. This work also provides insights for development of decision-support tools for improving short- and long-term outcomes in diabetes care.

Neural Physiological Model: A Simple Module for Blood Glucose Prediction

Continuous glucose monitors (CGM) and insulin pumps are becoming increasingly important in diabetes management. Additionally, data streams from these devices enable the prospect of accurate blood glucose prediction to support patients in preventing adverse glycemic events. In this paper, we present Neural Physiological Encoder (NPE), a simple module that leverages decomposed convolutional filters to automatically generate effective features that can be used with a downstream neural network for blood glucose prediction. To our knowledge, this is the first work to investigate a decomposed architecture in the diabetes domain. Our experimental results show that the proposed NPE model can effectively capture temporal patterns and blood glucose associations with other daily activities. For predicting blood glucose 30-mins in advance, NPE+LSTM yields an average root mean square error (RMSE) of 9.18 mg/dL on an in-house diabetes dataset from 34 subjects. Additionally, it achieves state-of-the-art RMSE of 17.80 mg/dL on a publicly available diabetes dataset (OhioT1DM) from 6 subjects.

Knowledge-driven dictionaries for sparse representation of continuous glucose monitoring signals

Continuous glucose monitoring (CGM) of patients with diabetes allows the effective management of the disease and reduces the risk of hypoglycemic or hyperglycemic episodes. Towards this goal, the development of reliable CGM models is essential for representing the corresponding signals and interpreting them with respect to factors and outcomes of interest. We propose a sparse decomposition model to approximate CGM time-series as a linear combination of a small set of exemplar atoms, appropriately designed through parametric functions to capture the main fluctuations of the CGM signal. Sparse decomposition is performed through the orthogonal matching pursuit (OMP). Results indicate that the proposed model provides 0.1 relative reconstruction error with 0.8 compression rate on a publicly available dataset containing 25 patients diagnosed with Type 1 diabetes. The atoms selected from the OMP procedure can be further interpreted in relation to the clinically meaningful components of the CGM signal (e.g. glucose spikes, hypoglycemic episodes, etc.

EarBit: Using Wearable Sensors to Detect Eating Episodes in Unconstrained Environments

Chronic and widespread diseases such as obesity, diabetes, and hypercholesterolemia require patients to monitor their food intake, and food journaling is currently the most common method for doing so. However, food journaling is subject to self-bias and recall errors, and is poorly adhered to by patients. In this paper, we propose an alternative by introducing EarBit, a wearable system that detects eating moments. We evaluate the performance of inertial, optical, and acoustic sensing modalities and focus on inertial sensing, by virtue of its recognition and usability performance. Using data collected in a simulated home setting with minimum restrictions on participants' behavior, we build our models and evaluate them with an unconstrained outside-the-lab study. For both studies, we obtained video footage as ground truth for participants activities. Using leave-one-user-out validation, EarBit recognized all the eating episodes in the semi-controlled lab study, and achieved an accuracy of 90.1% and an F₁-score of 90.9% in detecting chewing instances. In the unconstrained, outside-the-lab evaluation, EarBit obtained an accuracy of 93% and an F₁-score of 80.1% in detecting chewing instances. It also accurately recognized all but one recorded eating episodes. These episodes ranged from a 2 minute snack to a 30 minute meal.

Exploring Symmetric and Asymmetric Bimanual Eating Detection with Inertial Sensors on the Wrist

Motivated by health applications, eating detection with off-the-shelf devices has been an active area of research. A common approach has been to recognize and model individual intake gestures with wrist-mounted inertial sensors. Despite promising results, this approach is limiting as it requires the sensing device to be worn on the hand performing the intake gesture, which cannot be guaranteed in practice. Through a study with 14 participants comparing eating detection performance when gestural data is recorded with a wrist-mounted device on (1) both hands, (2) only the dominant hand, and (3) only the non-dominant hand, we provide evidence that a larger set of arm and hand movement patterns beyond food intake gestures are predictive of eating activities when L1 or L2 normalization is applied to the data. Our results are supported by the theory of asymmetric bimanual action and contribute to the field of automated dietary monitoring. In particular, it shines light on a new direction for eating activity recognition with consumer wearables in realistic settings.

Unobtrusive and Wearable Systems for Automatic Dietary Monitoring

The threat of obesity, diabetes, anorexia, and bulimia in our society today has motivated extensive research on dietary monitoring. Standard self-report methods such as 24-h recall and food frequency questionnaires are expensive, burdensome, and unreliable to handle the growing health crisis. Long-term activity monitoring in daily living is a promising approach to provide individuals with quantitative feedback that can encourage healthier habits. Although several studies have attempted automating dietary monitoring using wearable, handheld, smart-object, and environmental systems, it remains an open research problem. This paper aims to provide a comprehensive review of wearable and hand-held approaches from 2004 to 2016. Emphasis is placed on sensor types used, signal analysis and machine learning methods, as well as a benchmark of state-of-the art work in this field. Key issues, challenges, and gaps are highlighted to motivate future work toward development of effective, reliable, and robust dietary monitoring systems.