Astrid Atakov-Castillo

Dietary Fat Acutely Increases Glucose Concentrations and Insulin Requirements in Patients With Type 1 Diabetes: Implications for carbohydrate-based bolus dose calculation and intensive diabetes management

OBJECTIVE Current guidelines for intensive treatment of type 1 diabetes base the mealtime insulin bolus calculation exclusively on carbohydrate counting. There is strong evidence that free fatty acids impair insulin sensitivity. We hypothesized that patients with type 1 diabetes would require more insulin coverage for higher-fat meals than lower-fat meals with identical carbohydrate content. RESEARCH DESIGN AND METHODS We used a crossover design comparing two 18-h periods of closed-loop glucose control after high-fat (HF) dinner compared with low-fat (LF) dinner. Each dinner had identical carbohydrate and protein content, but different fat content (60 vs. 10 g). RESULTS Seven patients with type 1 diabetes (age, 55 ± 12 years; A1C 7.2 ± 0.8%) successfully completed the protocol. HF dinner required more insulin than LF dinner (12.6 ± 1.9 units vs. 9.0 ± 1.3 units; P = 0.01) and, despite the additional insulin, caused more hyperglycemia (area under the curve >120 mg/dL = 16,967 ± 2,778 vs. 8,350 ± 1,907 mg/dL⋅min; P < 0001). Carbohydrate-to-insulin ratio for HF dinner was significantly lower (9 ± 2 vs. 13 ± 3 g/unit; P = 0.01). There were marked interindividual differences in the effect of dietary fat on insulin requirements (percent increase significantly correlated with daily insulin requirement; R2 = 0.64; P = 0.03). CONCLUSIONS This evidence that dietary fat increases glucose levels and insulin requirements highlights the limitations of the current carbohydrate-based approach to bolus dose calculation. These findings point to the need for alternative insulin dosing algorithms for higher-fat meals and suggest that dietary fat intake is an important nutritional consideration for glycemic control in individuals with type 1 diabetes.

Psychosocial factors associated with use of continuous glucose monitoring

Diabet. Med. 27, 1060–1065 (2010)

Patient-Provider Relationships Across the Transition From Pediatric to Adult Diabetes Care A Qualitative Study

Purpose The purpose of this study was to explore perceptions that emerging adults with type 1 diabetes (T1D) have of their patient-provider relationships across the transition from pediatric to adult care. Methods Twenty-six emerging adults with T1D (mean age 26.2 ± 2.5 years) participated in 5 focus groups stratified by current level of glycemic control (A1C). Coded audio-recorded data were analyzed using thematic analysis and aided by NVivo software. Results Three major themes emerged from the analysis: (1) loss and gain in provider relationships across the transition—patients expressed 3 key responses to leaving pediatric providers that differed by A1C levels: sad reluctance and “natural progression” (mean A1C ± SD 7.4% ± 0.6%) and wanting to go (mean A1C ± SD 9.8% ± 1.0%); (2) partners in care versus on one’s own—patients valued how adult providers’ collaborative conversations promoted their involvement and accountability compared to “parent-centric” interactions with pediatric providers, but they also expressed ambivalence over increased independence in adult care; (3) improving provider approaches to transition—patients recommended that pediatric providers actively promote emerging adults’ autonomy while maintaining parental support, communication with adult providers, and follow-up with transitioning patients. Conclusions Findings highlight the importance of enhanced provider awareness of T1D emerging adults’ complex feelings about the transition in care. Improved integration of individual- and family-centered approaches to developmentally tailored diabetes care is needed to augment patient and provider relationships.

Experiences of health care transition voiced by young adults with type 1 diabetes: a qualitative study

Objective This qualitative study aimed to explore the experience of transition from pediatric to adult diabetes care reported by posttransition emerging adults with type 1 diabetes (T1D), with a focus on preparation for the actual transfer in care. Methods Twenty-six T1D emerging adults (mean age 26.2±2.5 years) receiving adult diabetes care at a single center participated in five focus groups stratified by two levels of current glycemic control. A multidisciplinary team coded transcripts and conducted thematic analysis. Results Four key themes on the process of transfer to adult care emerged from a thematic analysis: 1) nonpurposeful transition (patients reported a lack of transition preparation by pediatric providers for the transfer to adult diabetes care); 2) vulnerability in the college years (patients conveyed periods of loss to follow-up during college and described health risks and diabetes management challenges specific to the college years that were inadequately addressed by pediatric or adult providers); 3) unexpected differences between pediatric and adult health care systems (patients were surprised by the different feel of adult diabetes care, especially with regards to an increased focus on diabetes complications); and 4) patients’ wish list for improving the transition process (patients recommended enhanced pediatric transition counseling, implementation of adult clinic orientation programs, and peer support for transitioning patients). Conclusion Our findings identify modifiable deficiencies in the T1D transition process and underscore the importance of a planned transition with enhanced preparation by pediatric clinics as well as developmentally tailored patient orientation in the adult clinic setting.

Impact of continuous glucose monitoring on diabetes management and marital relationships of adults with Type 1 diabetes and their spouses: a qualitative study

To examine the impact of continuous glucose monitoring on diabetes management and marital relationships of adults with Type 1 diabetes and their spouses.

The artificial pancreas: evaluating risk of hypoglycaemia following errors that can be expected with prolonged at-home use

Artificial pancreas systems show benefit in closely monitored at‐home studies, but may not have sufficient power to assess safety during infrequent, but expected, system or user errors. The aim of this study was to assess the safety of an artificial pancreas system emulating the β–cell when the glucose value used for control is improperly calibrated and participants forget to administer pre‐meal insulin boluses.