Larry C. Deeb

Recommendations for Standardizing Glucose Reporting and Analysis to Optimize Clinical Decision Making in Diabetes: The Ambulatory Glucose Profile (AGP)

Abstract Underutilization of glucose data and lack of easy and standardized glucose data collection, analysis, visualization, and guided clinical decision making are key contributors to poor glycemic control among individuals with type 1 diabetes. An expert panel of diabetes specialists, facilitated by the International Diabetes Center and sponsored by the Helmsley Charitable Trust, met in 2012 to discuss recommendations for standardization of analysis and presentation of glucose monitoring data, with the initial focus on data derived from CGM systems. The panel members were introduced to a universal software report, the Ambulatory Glucose Profile (AGP), and asked to provide feedback on its content and functionality, both as a research tool and in clinical settings. This paper provides a summary of the topics and issues discussed during the meeting and presents recommendations from the expert panel regarding the need to standardize glucose profile summary metrics and the value of a uniform glucose report to aid clinicians, researchers, and patients.

Diabetes care in the school and day care setting.

D iabetes is one of the most common chronic diseases of childhood (1). There are ;215,000 individuals ,20 years of age with diabetes in the U.S. (2). The majority of these young people attend school and/or some type of day care and need knowledgeable staff to provide a safe school environment. Both parents and the health care team should work together to provide school systems and day care providers with the information necessary to allow children with diabetes to participate fully and safely in the school experience (3,4).

Type 2 diabetes mellitus among Florida children and adolescents, 1994 through 1998

OBJECTIVES This study was undertaken to examine the trends in the diagnosis of Type 2 diabetes mellitus among children and adolescents with new-onset diabetes seen from 1994 through 1998 at the three university-based diabetes centers in Florida. METHODS Data were abstracted from medical records and patients were categorized as having Type 1 or Type 2 diabetes. RESULTS There were 569 patients classified with Type 1 diabetes and 92 with Type 2 diabetes. The proportion of patients diagnosed with Type 2 diabetes increased over the five years from 9.4% in 1994 to 20.0% in 1998 (chi-square test for trend = 8.2; p=0.004). There was not an associated net increase in the total number of new diabetes patients referred over time (chi-square test for trend = 0.6, p=0.4). Those with Type 2 diabetes were more likely to have a body mass index in the 85th-94th percentile [odds ratio (OR) = 8.5; 95% confidence interval (CI) 2.5, 28.8], have a body mass index >or=95th percentile (OR = 6.8; 95% CI 2.6, 17.7), Hispanic ethnicity (OR = 6.2; 95% CI 2.2, 17.9), black race (OR = 2.8; 95% CI 1.3, 6.2), female gender (OR = 2.2; 95% CI 1.2, 4.3), and older age (OR = 1.4 for each one-year increment in age; 95% CI 1.3, 1.6), compared with those having Type 1 diabetes. CONCLUSIONS From 1994 through 1998, there was a significant overall increase in the percentage of children referred with new-onset diabetes who were considered to have Type 2 diabetes. Factors associated with the diagnosis of Type 2 diabetes relative to Type 1 diabetes include body mass index >/=85th percentile, Hispanic ethnicity, black race, female gender, and older age.

Impact of a Telemedicine System with Automated Reminders on Outcomes in Women with Gestational Diabetes Mellitus

BACKGROUND Health information technology has been proven to be a successful tool for the management of patients with multiple medical conditions. The purpose of this study was to examine the impact of an enhanced telemedicine system on glucose control and pregnancy outcomes in women with gestational diabetes mellitus (GDM). SUBJECTS AND METHODS We used an Internet-based telemedicine system to also allow interactive voice response phone communication between patients and providers and to provide automated reminders to transmit data. Women with GDM were randomized to either the telemedicine group (n=40) or the control group (n=40) and asked to monitor their blood glucose levels four times a day. Women in the intervention group transmitted those values via the telemedicine system, whereas women in the control group maintained paper logbooks, which were reviewed at prenatal visits. Primary outcomes were infant birth weight and maternal glucose control. Data collection included blood glucose records, transmission rates for the intervention group, and chart review. RESULTS There were no significant differences between the two groups (telemedicine vs. controls) in regard to maternal blood glucose values or infant birth weight. However, adding telephone access and reminders increased transmission rates of data in the intervention group compared with the intervention group in our previous study (35.6±32.3 sets of data vs.17.4±16.9 sets of data; P<0.01). CONCLUSIONS Our enhanced telemedicine monitoring system increased system utilization and contact between women with GDM and their healthcare providers but did not impact upon pregnancy outcomes.

Recommendations for standardizing glucose reporting and analysis to optimize clinical decision making in diabetes: the ambulatory glucose profile.

Underutilization of glucose data and lack of easy and standardized glucose data collection, analysis, visualization, and guided clinical decision making are key contributors to poor glycemic control among individuals with type 1 diabetes mellitus. An expert panel of diabetes specialists, facilitated by the International Diabetes Center and sponsored by the Helmsley Charitable Trust, met in 2012 to discuss recommendations for standardizing the analysis and presentation of glucose monitoring data, with the initial focus on data derived from continuous glucose monitoring systems. The panel members were introduced to a universal software report, the Ambulatory Glucose Profile, and asked to provide feedback on its content and functionality, both as a research tool and in clinical settings. This article provides a summary of the topics and issues discussed during the meeting and presents recommendations from the expert panel regarding the need to standardize glucose Profile summary metrics and the value of a uniform glucose report to aid clinicians, researchers, and patients.

Risk Factors Associated with Depressive Symptoms in Caregivers of Children with Type 1 Diabetes or Cystic Fibrosis

OBJECTIVE Evaluate depressive symptoms in caregivers of children with type 1 diabetes (T1D) or cystic fibrosis (CF) and identify associated risk factors. METHODS A total of 195 caregivers completed demographic, stress, and depressive symptoms questionnaires. Childrens health status was obtained from medical records. RESULTS Approximately 33% of caregivers reported elevated symptoms of depression (i.e., exceeded clinical cutoff of 16 on the Center for Epidemiological Studies-Depression Scale). For caregivers of children with T1D, elevations were associated with less caregiver education, more family stress, older child age, and worse glycemic control. For caregivers of children with CF, more family stress and lack of employment outside of the home were associated with elevated depressive symptoms. CONCLUSIONS Many caregivers of children with T1D or CF experience depressive symptoms, although risk factors may differ in these two populations. Screening of caregiver depressive symptoms as part of routine clinic visits may provide opportunities for needed intervention.

Insulin degludec in combination with bolus insulin aspart is safe and effective in children and adolescents with type 1 diabetes

Insulin degludec (IDeg) once‐daily was compared with insulin detemir (IDet) once‐ or twice‐daily, with prandial insulin aspart in a treat‐to‐target, randomized controlled trial in children 1–17 yr with type 1 diabetes, for 26 wk (n = 350), followed by a 26‐wk extension (n = 280). Participants were randomized to receive either IDeg once daily at the same time each day or IDet given once or twice daily according to local labeling. Aspart was titrated according to a sliding scale or in accordance with an insulin:carbohydrate ratio and a plasma glucose correction factor. Randomization was age‐stratified: 85 subjects 1–5 yr. (IDeg: 43), 138 6–11 yr (IDeg: 70) and 127 12–17 yr (IDeg: 61) were included. Baseline characteristics were generally similar between groups overall and within each stratification. Non‐inferiority of IDeg vs. IDet was confirmed for HbA1c at 26 wk; estimated treatment difference (ETD) 0.15% [−0.03; 0.32]95%CI. At 52 wk, HbA1c was 7.9% (IDeg) vs. 7.8% (IDet), NS; change in mean FPG was −1.29 mmol/L (IDeg) vs. +1.10 mmol/L (IDet) (ETD −1.62 mmol/L [−2.84; −0.41]95%CI, p = 0.0090) and mean basal insulin dose was 0.38 U/kg (IDeg) vs. 0.55 U/kg (IDet). The majority of IDet treated patients (64%) required twice‐daily administration to achieve glycemic targets. Hypoglycemia rates did not differ significantly between IDeg and IDet, but confirmed and severe hypoglycemia rates were numerically higher with IDeg (57.7 vs. 54.1 patient‐years of exposure (PYE) [NS] and 0.51 vs. 0.33, PYE [NS], respectively) although nocturnal hypoglycemia rates were numerically lower (6.0 vs. 7.6 PYE, NS). Rates of hyperglycemia with ketosis were significantly lower for IDeg vs. IDet [0.7 vs. 1.1 PYE, treatment ratio 0.41 (0.22; 0.78)95%CI, p = 0.0066]. Both treatments were well tolerated with comparable rates of adverse events. IDeg achieved equivalent long‐term glycemic control, as measured by HbA1c with a significant FPG reduction at a 30% lower basal insulin dose when compared with IDet. Rates of hypoglycemia did not differ significantly between the two treatment groups; however, hyperglycemia with ketosis was significantly reduced in those treated with IDeg.

Assessing diabetes‐related quality of life of youth with type 1 diabetes in routine clinical care: the MIND Youth Questionnaire (MY‐Q)

It is recommended to assess health‐related quality of life (HRQoL) in teenagers with diabetes as part of their ongoing medical care. Here, we describe the development and psychometric evaluation of the Monitoring Individual Needs in Diabetes Youth Questionnaire (MY‐Q), a multi‐dimensional self‐report HRQoL questionnaire designed for use in pediatric diabetes care.

Parent Reactions to a School-Based Body Mass Index Screening Program

BACKGROUND This study assessed parent reactions to school-based body mass index (BMI) screening. METHODS After a K-8 BMI screening program, parents were sent a letter detailing their childs BMI results. Approximately 50 parents were randomly selected for interview from each of 4 child weight-classification groups (overweight, at risk of overweight, normal weight, underweight) to assess parent recall of the letter, reactions to BMI screening, and actions taken in response to the childs BMI results. RESULTS Most parents found the BMI screening letter easy to read and had poor recall of numerical information (eg, the childs BMI percentile) but good recall of the childs weight classification (eg, normal weight or overweight). Most parents, and ethnic-minority parents in particular, supported school-based BMI screening. Parents of children whose weight was outside of the normal range were more likely to recall receiving the letter and talking to the child and the childs doctor about it. Parents who recalled their child as being overweight were more likely to report changing the childs diet and activity level. Most parents, and ethnic-minority parents in particular, wanted their child to participate in an after-school exercise program. An overweight condition in parents, but not children, was associated with an interest in family-based cooking and exercise classes. CONCLUSIONS Most parents, and ethnic-minority parents in particular, viewed school-based BMI screening and after-school exercise programs favorably. Parents reported taking action in response to a BMI result outside of the normal range. Parents who were overweight themselves were particularly interested in family cooking and exercise classes.

Care of Young Children With Diabetes in the Child Care Setting: A Position Statement of the American Diabetes Association

Diabetes is a relatively common chronic disease of childhood (1); however, capturing prevalence data in children with type 1 and type 2 diabetes has been challenging. The comprehensive SEARCH for Diabetes in Youth (SEARCH) study has made significant strides in better understanding disease prevalence in the pediatric population. A recent SEARCH study found that 1.93 per 1,000 youth (aged <20 years) were diagnosed with type 1 diabetes (2), an increase of 21.1% from 2001 to 2009, with increases seen in all ethnic groups but with non-Hispanic whites disproportionately affected (3). For type 2 diabetes, the SEARCH study reported a prevalence of 0.46 per 1,000 youth (aged 10–20 years), an increase of 30.5% from 2001 to 2009 in all ethnicities (3). As youth rarely die of diabetes, the increase in prevalence is most likely attributed to increased incidence. An annual increase of 2.3% in type 1 diabetes incidence has been reported in children, with children aged <5 years experiencing the greatest increase relative to all children (4). As type 2 diabetes is rarely seen in children younger than 10 years of age (3), this Position Statement will primarily focus on type 1 diabetes. The primary objective of this Position Statement is to explain that young children (aged ≤5 years) are a vulnerable population and have unique diabetes management needs. Our goal is to describe the diabetes management recommendations in the child care setting. The child care setting includes day care, camp, and other programs where young children with diabetes are enrolled. This Position Statement is meant to guide child care providers in caring for young children with diabetes and is not intended to provide specific advice on the medical management for this population. While Position Statements contain evidence-based recommendations, all of the information that pertains to young children is expert opinion …