Michelle Katz

Family‐based psychoeducation and care ambassador intervention to improve glycemic control in youth with type 1 diabetes: a randomized trial

Youth with type 1 diabetes frequently do not achieve glycemic targets. We aimed to improve glycemic control with a Care Ambassador (CA) and family‐focused psychoeducational intervention.

Contemporary rates of severe hypoglycaemia in youth with Type 1 diabetes: variability by insulin regimen

Diabet. Med. 29, 926–932 (2012)

Associations of nutrient intake with glycemic control in youth with type 1 diabetes: differences by insulin regimen.

BACKGROUND Type 1 diabetes management has evolved from meal plans towards flexible eating with carbohydrate counting. With this shift, youth with type 1 diabetes may consume excess fat and insufficient fiber, which may impact glycemic control. Few studies consider whether insulin regimen influences associations between dietary intake and hemoglobin A1c. PATIENTS AND METHODS In this cross-sectional study, 252 youth (52% male; age, 13.2 ± 2.8 years; body mass index z-score [z-BMI], 0.7 ± 0.8) with type 1 diabetes completed 3-day food records. Dietary intake was compared with published guidelines. Logistic regression predicted the odds of suboptimal glycemic control (an A1c level of ≥ 8.5%) related to fat and protein intake or fiber intake according to insulin regimen (pump vs. injection) adjusting for age, sex, diabetes duration, z-BMI, insulin dose, glucose monitoring frequency, and total energy intake (TEI). RESULTS Youth had a mean TEI of 40.9 ± 15.4 kcal/kg/day and excess fat and insufficient fiber intake compared against published guidelines. Pump-treated youth consuming the highest quartile of fat intake (as percentage TEI) had 3.6 (95% confidence interval, 1.3-9.7) times the odds of a suboptimal A1c than those in the lowest quartile. No such association was found in injection-treated youth. In the total sample, youth with the lowest quartile of fiber intake had 3.6 (95% confidence interval, 1.4-9.0) times the odds of a suboptimal A1c, but this association did not differ by insulin regimen. There was no association between protein intake and A1c. CONCLUSIONS Higher fat intake in pump-treated youth and lower fiber intake in all youth were associated with an A1c level of ≥ 8.5%. Improving dietary quality may help improve A1c.

Mortality in Type 1 Diabetes in the Current Era Two Steps Forward, One Step Backward

cular disease in those treated with intensive insulin therapy vs conventional therapy during the trial. 8 In the current report, based on 107 deaths among 1429 participants, those randomized to intensive insulin therapy, compared to those randomized to conventional therapy, had lower all-cause mortality (43 deaths vs 64 deaths, respectively; hazard ratio, 0.67 [95% CI, 0.46-0.99], P = .045). The most common causes of death were cardiovascular disease (22%), cancer (20%), and acute complications (18%). Notably, all-cause mortality was significantly

Challenges and Opportunities in the Management of Cardiovascular Risk Factors in Youth With Type 1 Diabetes: Lifestyle and Beyond

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in persons with type 1 diabetes (T1D). Specific risk factors associated with diabetes, such as hyperglycemia and kidney disease, have been demonstrated to increase the incidence and progression of CVD. Nevertheless, few data exist on the effects of traditional risk factors such as dyslipidemia, obesity, and hypertension on CVD risk in youth with T1D. Improvements in understanding and approaches to the evaluation and management of CVD risk factors, specifically for young persons with T1D, are desirable. Recent advances in noninvasive techniques to detect early vascular damage, such as the evaluation of endothelial dysfunction and aortic or carotid intima-media thickness, provide new tools to evaluate the progression of CVD in childhood. In the present review, current CVD risk factor management, challenges, and potential therapeutic interventions in youth with T1D are described.

Youth and Parent Measures of Self-Efficacy for Continuous Glucose Monitoring: Survey Psychometric Properties

BACKGROUND This study aimed to describe the development and psychometric evaluation of novel youth and parent measures of self-efficacy related to continuous glucose monitoring (CGM) in pediatric patients with type 1 diabetes. This evaluation also assessed the predictive validity of the CGM Self-Efficacy (CGM-SE) surveys on CGM use and hemoglobin A1c (HbA1c) levels. SUBJECTS AND METHODS Study participants included 120 youth with type 1 diabetes for ≥1 year enrolled in a 2-year randomized clinical trial comparing CGM use with and without the addition of a family-focused CGM behavioral intervention. Youth and parents completed the CGM-SE surveys at randomization after a 1-week run-in to assess CGM tolerability. Analyses of predictive validity excluded the intervention group and included 61 youth in the control group in order to assess CGM use and HbA1c outcomes 3 and 6 months after randomization. RESULTS At study entry, youth were 12.7±2.7 years old with a diabetes duration of 6.1±3.6 years and an HbA1c level of 8.0±0.8% (64±9 mmol/mol); blood glucose monitoring frequency was 6.8±2.4 times/day, and 84% received pump therapy. CGM-SE surveys had acceptable internal consistency (Cronbachs α=0.80 for youth and 0.82 for parents). Youth reporting higher baseline CGM self-efficacy (CGM-SE score of >80) had significantly greater CGM use and lower HbA1c level after 3 and 6 months compared with youth reporting lower baseline CGM self-efficacy (CGM-SE score of ≤80). CONCLUSIONS The CGM-SE surveys appear to have strong psychometric properties. CGM self-efficacy may offer an opportunity to assess the likelihood of CGM adherence and glycemic improvement in youth with type 1 diabetes in clinical and research settings.

Influence of HbA1c and BMI on Lipid Trajectories in Youths and Young Adults With Type 1 Diabetes.

OBJECTIVE To assess the influence of HbA1c and BMI (measured as BMI z score [zBMI]) on LDL, HDL, and non-HDL trajectories as youths with type 1 diabetes age into early adulthood. RESEARCH DESIGN AND METHODS Dynamic, retrospective cohort study examining changes in lipid values in 572 youths with type 1 diabetes followed longitudinally for a median of 9.3 years. Through longitudinal modeling, we describe the relationship of HbA1c and zBMI on lipid values as subjects age after adjusting for other relevant factors, including lipid-lowering medication use. RESULTS The median number of lipid assessments was 7 (range 2–39). Every 1% increase in HbA1c was associated with an ∼2–6 mg/dL increase in LDL levels, with a greater increase in LDL levels as subjects progressed from prepubertal to postpubertal age ranges. A 1-SD increase in BMI was associated with a mean LDL increase of 2.1 mg/dL when subjects were 10 years old and increased to a mean of 8.2 mg/dL when subjects were 19 years old. The association between changes in HbA1c level and zBMI and changes in non-HDL levels as youths aged were similar to the associations found with LDL. The influence of HbA1c and zBMI on HDL levels was small and not dependent on age. CONCLUSIONS Changes in HbA1c level and zBMI modestly impact LDL and non-HDL cholesterol and have greater impacts as children age. Addressing elevations in HbA1c and zBMI as children enter into adolescence and beyond may lead to improvements in lipid levels.

Validation of the Diabetes Family Impact Scale: a new measure of diabetes‐specific family impact

To develop and validate the Diabetes Family Impact Scale, a scale to measure the impact of diabetes on families.

Recruitment Into a Pediatric Continuous Glucose Monitoring RCT: Patient and Recruitment Process Characteristics Associated With Decision to Participate.

Background: The purpose was to identify patient/family characteristics and recruitment process characteristics associated with the decision to participate in a 2-year continuous glucose monitoring (CGM) RCT for youth with type 1 diabetes and their families. Method: Study staff approached patients who were conditionally eligible according to medical record review or referred by a provider. We categorized families according to participation decision (agree vs decline) and timing of decision (day of approach vs later [“thinkers”]). Results: Over 18 months, we approached 456 eligible patients; 19% agreed on the day of approach, 10% agreed later, 42% declined on the day of approach, and 30% declined later. Agreers were younger (P = .002), had shorter diabetes duration (P = .0003), had a lower insulin dose (P = .02), checked blood glucose levels more often (P = .002), and were more likely to use pump therapy (P = .009) than decliners. Patients/families were more likely to agree in fall/winter (41%) than spring/summer (19%, P < .0001). Of decliners, 50% cited no interest in CGM as the reason for nonparticipation. Among thinkers, 49% of patients who made a decision within 2 weeks of being approached agreed; only 15% of thinkers who made a decision >2 weeks after being approached agreed to participate (P < .0001). Conclusions: Recruitment is a critical and often challenging phase of clinical trials. Recruitment to pediatric CGM studies may be especially challenging due to youths’ reluctance to use CGM. These data provide an opportunity to better understand and possibly optimize recruitment into future pediatric CGM studies and other studies of advanced diabetes technologies.

Management of Hypertension and High Low-Density Lipoprotein in Pediatric Type 1 Diabetes

Objective To evaluate hypertension and hyperlipidemia management patterns in youth with type 1 diabetes and to assess perceived effectiveness of management strategies and barriers to management. Study design An electronic survey, including clinical scenarios, fielded to pediatric providers (members of the American Diabetes Association Diabetes in Youth Interest Group, Pediatric Endocrine Society, or T1D Exchange). Results Respondents (N = 207, 86% MDs, 68% female) were practicing clinicians for youth with type 1 diabetes. As an initial recommendation, the overwhelming majority of respondents (83%‐99%) endorsed lifestyle and nonmedical recommendations (eg, improve glycemic control) for hypertension and hyperlipidemia. Yet, few (6%‐17%) reported these recommendations as effective. Many respondents (57%) reported referring to another specialist for hypertension, whereas few (8%) reported referring to another specialist for hyperlipidemia management. Approximately one‐fifth (21%) of respondents never initiate antihypertensive medications, whereas only 8% never initiate lipid‐lowering medication. Among prescribers, the majority of respondents only started antihypertensive or lipid‐lowering medications after persistent elevations and in the setting of either ineffective lifestyle or nonmedical interventions or additional cardiovascular risk factors. More than two‐thirds of respondents endorsed medications as often effective for hypertension and hyperlipidemia (68% and 69%, respectively). Conclusions Pediatric diabetes providers commonly defer prescribing antihypertensive and lipid‐lowering medications until nonmedication interventions have been ineffective. Most providers describe medications, but not lifestyle interventions, as often effective. Efforts to align clinical practice with clinical guidelines are needed.