Elaine Parton

The prevalence and clinical characteristics of celiac disease in juvenile diabetes in Wisconsin.

Background The relationship between celiac disease and juvenile diabetes has long been known. Only a single study in the United States, from Buffalo, New York, has reported the prevalence of celiac disease in a pediatric diabetic population. This study was conducted to determine the prevalence and clinical presentation of celiac disease in children and adolescents with juvenile diabetes in Wisconsin, U.S.A., using serum antiendomysial antibody as a screening test. Methods Two hundred eighteen patients with diabetes (113 males; age range, 4–21 years) and 117 age-and gender-matched control participants were tested for immunoglobulin A endomysial antibody. Patients with positive results were offered a small bowel biopsy. A questionnaire regarding abdominal pain, diarrhea, and growth failure was completed by the parents. Results Seventeen of 218 diabetic patients (7.7%) had positive endomysial antibody. All control participants had negative results for the endomysial antibody. Small bowel biopsy was performed in 14 patients. Ten patients had villous atrophy. In one patient without villous atrophy, a repeat biopsy 2 years later showed villous atrophy, and two patients had increased intraepithelial lymphocytes without villous atrophy. Seventy percent of the patients with celiac disease were asymptomatic. The reported symptoms were abdominal pain and diarrhea (n = 1) and growth failure (n = 2). Two patients with celiac disease had Down syndrome. Conclusions The prevalence of celiac disease in children with juvenile diabetes in Wisconsin is at least 4.6%, which is comparable with European and Canadian studies. Because patients without villous atrophy may have latent celiac disease, the prevalence may be even higher. All children with juvenile diabetes should be screened for celiac disease.

The impact of cognitive distortions, stress, and adherence on metabolic control in youths with type 1 diabetes.

PURPOSE To investigate the role of cognitive distortions in the relationship between adherence behavior, diabetes-specific stress, general stress, and metabolic control. METHODS Obtained questionnaire data, glucometer readings, and glycosylated hemoglobin (HbgA(1c)) assays from 143 youths (11-18 years old) with type 1 diabetes. Examined path model of relationships between cognitive distortions, stress, adherence behavior, and metabolic control. Data were analyzed using path analysis. RESULTS Higher levels of negative cognitive distortions were associated with more stress (both diabetes-specific and general). Higher levels of general stress then led to less adherent behavior and subsequently poorer metabolic control (higher HbgA(1c)). More diabetes-specific stress also led to poorer metabolic control, as well as general stress. CONCLUSIONS The findings indicate an indirect role of negative cognitive distortions in metabolic control. The current findings suggest that instead of the proposed direct link between cognitive distortions and adherence behavior, an indirect relationship may exist through stress.

A Stress Management Intervention for Adolescents With Type I Diabetes

PURPOSE The purpose of this project was to examine the effectiveness of a stress management training program in helping adolescents with diabetes cope with stress. METHODS Youths who displayed evidence of metabolic control problems received training in the use of both cognitive-restructuring and problem-solving strategies. Treatment impact was assessed on measures of coping, anxiety level, diabetes-specific stress, and metabolic control. RESULTS Analyses of covariance showed no differences between the training group and a control group at posttest and follow-up. However, the small sample size and within-group variability may have precluded finding significant results. Therefore, within-group comparisons were conducted, and improvements were found in the training group on pretest to posttest and pretest to follow-up comparisons for anxiety, stress, and coping measures. No differences were found in the control group. CONCLUSIONS Results suggest that the intervention had some positive impact, although this interpretation must be considered preliminary. Future research should replicate this study and explore the applicability and effectiveness of this intervention in specific populations.

Glucose Sensor Evaluation of Glycemic Instability in Pediatric Type 1 Diabetes Mellitus

Maintaining blood glucose (BG) levels within the target range can be an elusive goal in children with type 1 diabetes mellitus (DM). To identify factor(s) that may contribute to glycemic instability, we analyzed the Continuous Glucose Monitoring System (CGMS) (Medtronic MiniMed, Northridge, CA) profiles of a group of children with type 1 DM and a history of frequent BG fluctuations and hypoglycemia. A total of 30 (17 girls, 13 boys) pediatric patients with a history of frequent BG fluctuations and hypoglycemia (mean age, 10.5 +/- 0.7 years; duration, 5.0 +/- 0.6 years), on three to four injections of insulin daily or insulin pump therapy, were evaluated by the CGMS. The mean BG (MBG), absolute means of daily differences (MODD), mean amplitude of glycemic excursion (MAGE), and number of hypoglycemic events (BG <60 mg/dL) for 48 h were calculated in each patient. There was a significant correlation between MBG and glycosylated hemoglobin (HbA1c) (r(2) = 0.22, p < 0.009). There was also a significant correlation between severity of lipohypertrophy and glycemic control (HbA1c) (r(2) = 0.20, p < 0.01). The MODD values had a positive correlation with the severity of injection site lipohypertrophy (r(2) = 0.37, p < 0.0003). The MAGE values had a positive correlation with bolus:basal insulin ratio (r(2) = 0.22, p < 0.009) and number of hypoglycemic events (r(2) = 0.21, p < 0.008), independent of age, MBG, and glycemic control. The 48-h CGMS profile can help characterize day-to-day and within-day BG variability and identify factors influencing glycemic instability in pediatric type 1 DM.

Contextual assessment of problematic situations identified by insulin pump using adolescents and their parents

For youth with type 1 diabetes mellitus (T1DM) using insulin pumps, maintaining metabolic control through appropriate selfcare is a complex biopsychosocial process reciprocally influenced by individual, familial, social, and technological variables. Adolescents (n 20) with T1DM using insulin pumps and their parents (n 34) were interviewed to determine (a) the most frequent and difficult situations faced by adolescents and their parents, (b) how the frequency and difficulty of these situations vary as a function of the respondent, the nature (content) of the problem, and the systemic context(s) in which problems occur, and (c) the relationship between the average difficulty rating and the youth’s metabolic control. The most frequently reported problematic situations were T1DM self-care. For youth these problems were predominantly related to social and peer contexts; parents identified problems primarily related to the family context. Implications and additional analyses are reported.

Factors Associated with Adherence to Continuous Subcutaneous Insulin Infusion in Pediatric Diabetes

BACKGROUND/AIMS Continuous subcutaneous insulin infusion (CSII) is a safe and effective alternative to insulin injections in pediatric type 1 diabetes mellitus. CSII can be associated with an increased risk of hypoglycemia and diabetic ketoacidosis (DKA) in some patients. In our Center, patients/guardians are screened for proficiency in diabetes management skills as a prerequisite to initiation of CSII. We reviewed the clinical data from our patients to assess the predictors associated with nonadherence to CSII therapy. METHODS We retrospectively collected clinical data on all our CSII initiations between July 1999 to June 2003, including: body mass index, hemoglobin A1c (HbA1c), total daily dose, bolus to basal insulin ratio, hypoglycemic episodes (blood glucose <60 mg/dL/week), mean fasting self-monitored blood glucose (SMBG), severity of lipohypertrophy, DKA, and pubertal status. RESULTS Forty-six patients 9.90 +/- 3.4 years old (28 girls and 18 boys) started CSII in the 4-year period. While 39 patients (85%) 9.8 +/- 3.5 years old currently remain on CSII, seven patients (15%) 11.2 +/- 0.9 years old discontinued CSII. Fifteen patients (32.6%) were prepubertal at CSII initiation, and none discontinued CSII in this cohort, whereas seven of 31 (22.6%) pubertal patients discontinued CSII. The patients who continued CSII were similar to the CSII-discontinued cohort at baseline. At 12 months, rising HbA1c was the only predictor of future nonadherence to CSII. At 24 months, the discontinuation group had higher mean fasting SMBG levels and severe lipohypertrophy (P < 0.05). None of the prepubertal patients discontinued CSII, while all seven patients (100%) in the CSII-discontinued group were pubertal (P < 0.001). CONCLUSIONS Extensive screening by a multidisciplinary diabetes team prior to initiation of CSII regimen results in relatively lower discontinuation rates and a higher chance of maintaining optimal glycemic control (HbA1C < 8%) compared to previous studies.

A Cognitive Behavioral Adherence Intervention for Adolescents with Type 1 Diabetes

This study examined the impact of a cognitive behavioral intervention for nonadherent adolescents with type 1 diabetes. Six youths having problems following the diabetes regimen received training in cognitive restructuring and problem solving during individual sessions. A multiple baseline design across participants was used. Treatment effectiveness was assessed through 24-hr recall adherence interviews with adolescents and frequency of testing data was downloaded from glucose meters. Data was also collected for diabetes-specific stress. Five youths displayed improvement on at least one self-care behavior. Furthermore, the results suggest that the cognitive behavioral intervention was effective in diminishing diabetes-related stress in two participants. Cognitive behavioral interventions show promise for increasing self-care behaviors among nonadherent youths with type 1 diabetes. However, individual youths varied in their response to treatment. Further research is needed in developing procedures to better meet the needs of youths, improve youth participation, and enhance treatment effectiveness.

Beneficial effects of flexible insulin therapy in children and adolescents with type 1 diabetes mellitus.

Abstract.The purpose of this study was to determine the feasibility of a flexible multiple daily insulin (FMDI) regimen in routine pediatric diabetes care by comparing HbA1c, body mass index (BMI), and episodes of severe hypoglycemia (SH) before and after initiation of FMDI therapy. Data from 44 patients (2–16 years old), on a conventional insulin (CI) regimen, were collected during quarterly diabetes clinic visits. These patients were transitioned from CI to FMDI regimen: pre-meal lispro (bolus) and once or twice daily Humulin Ultralente with or without bedtime Humulin NPH as the basal insulin. There was a significant improvement in HbA1c in prepubertal (9.3%±1.3% vs. 8.0%±1.1%, p<0.002) and pubertal subjects (9.2%±1.0% vs. 8.2%±0.9%, p<0.001). Pubertal subgroup demonstrated an increase in BMI (21.3±3.1 vs. 22.7±3.2 kg/m2, p<0.0001) after one year. The rate of SH was decreased in both prepubertal (p<0.01) and pubertal (p<0.05) groups of patients on FMDI therapy. The use of FMDI in a general pediatric diabetic population is a feasible therapeutic option for maintenance and possible improvement of glycemic control. It may effectively decrease the HbA1c, and reduce hypoglycemic episodes, without producing an abnormal increase in BMI.

Development of Optimal Kids Insulin Dosing System Formulas for Young Children with Type 1 Diabetes Mellitus

OBJECTIVE This study was designed to develop predictive formulas for precise insulin dosing in young children with type 1 diabetes (T1DM). RESEARCH DESIGN AND METHODS Consecutive 1-year data from a group of 14 young patients (eight girls, six boys) 3.9 ± 0.8 years old with diabetes duration of 2.0 ± 0.8 years, transitioned from multiple daily injections (MDI) to continuous subcutaneous insulin infusion (CSII), were analyzed to identify parameters governing optimal insulin dosing. Body mass index (BMI), total daily dose (TDD), total basal dose, insulin-to-carbohydrate ratio (ICR), correction factor (CF), and mean amplitude of glycemic excursion (MAGE) by continuous glucose monitoring and hemoglobin A(1c) (HbA(1c)) level were evaluated at baseline and every 3 months. The slopes of CF versus 1/TDD, bolus versus TDD, ICR versus 1/TDD, and CF versus ICR were determined. RESULTS Kids Insulin Dosing System (KIDS) slope constants at follow-up were associated with MAGE compared with baseline (P<0.0001) without significant changes in BMI (16.6 ± 1.5 vs. 16.7 ± 1.4 kg/m(2)) and HbA(1c) values (8.0 ± 0.50% vs. 7.8 ± 0.40%). The relationship between CF and TDD changed significantly during CSII compared with baseline MDI (P<0.0001), whereas the coefficients for ICR and TDD relationship remained relatively unchanged. The KIDS formulas estimated TDD=0.74×body weight, total basal dose=0.28×TDD, CF=2,800/TDD, and ICR=13.5×body weight/TDD. CONCLUSIONS The interrelationships among ICR, CF, TBD, and TDD remained stable on CSII and were accompanied by decreased glycemic excursions. The KIDS formulas may yield consistent and easy estimates of insulin dosing factors in very young patients with T1DM.

Feasibility of Continuous Subcutaneous Insulin Infusion and Daily Supplemental Insulin Glargine Injection in Children with Type 1 Diabetes

BACKGROUND Continuous subcutaneous insulin infusion (CSII) is an effective method of insulin substitution with increased risk of hypoglycemia and diabetic ketoacidosis (DKA) in rare situations. The lack of subcutaneous long-acting insulin and short half-life of serum insulin increases the risk of ketosis and DKA following CSII failure. We evaluated the metabolic effects of CSII with and without daily supplemental long-acting insulin glargine in a group of young children switched to CSII from multiple daily insulin (premeal aspart + glargine) to either CSII plus daily glargine (CSII + G) or CSII therapy. METHODS From retrospective clinic data, self-monitored blood glucose (SMBG), hemoglobin A1c (HbA(1c)), hypoglycemic episodes, and body mass index (BMI) were obtained from 12 patients (five girls, seven boys; 7.7 +/- 1.8 years) on CSII + G and 12 age- and gender-matched patients (five girls, seven boys; 7.7 +/- 2.1 years) on CSII with similar baseline HbA(1c) and BMI were reviewed over a 1.0-year period. RESULTS The insulin glargine dose in the CSII + G group was 30.6 +/- 12.4% (range, 13.9-53.3%) of daily basal insulin dose. Both groups had similar total daily insulin and bolus:basal insulin at baseline and at 1.0 year. Glycemic control improved in the CSII + G (SMBG, 195.5 +/- 47.3 vs. 156.8 +/- 36.8 mg/dL, P < 0.05; HbA(1c), 8.1 +/- 0.9% vs. 7.4 +/- 0.4%, P < 0.02) and CSII (SMBG, 198.7 +/- 45.7 vs. 161.4 +/- 30.9 mg/dL, P < 0.05; HbA(1c), 8.2 +/- 0.4% vs. 7.7 +/- 0.5%, P < 0.01) groups without significant changes in hypoglycemic episodes and BMI. There were no DKA episodes despite three emergency room visits for hyperglycemia and ketosis due to catheter dislodgement only in the CSII group. CONCLUSIONS CSII therapy with or without daily insulin glargine improved glycemic control without changes in the rate of hypoglycemia and DKA, suggesting that this treatment regimen is feasible and may also prevent development of hyperglycemia and ketosis or even DKA.