Success with lifestyle monotherapy in youth with new-onset type 2 diabetes

BACKGROUND:

Evidence is lacking to support the efficacy of lifestyle modification as first-line therapy in the clinical management of type 2 diabetes mellitus (T2DM) in adolescents.

METHODS:

A retrospective chart review of youth diagnosed with T2DM between 1999 and 2008 was conducted. The authors describe the percentage of youth presenting with glycosylated hemoglobin (HbA_1c) of <9% who achieved/maintained target glycemic control (HbA_1c ≤7.0%) with lifestyle monotherapy during the year following diagnosis.

RESULTS:

Among the 275 youth with T2DM, 38% (n=104) presented with an HbA_1c <9% and were prescribed lifestyle monotherapy at diagnosis. Of the 80 youth who had sufficient follow-up data over 12 months, 54% successfully maintained target glycemic control solely with lifestyle management. The mean HbA_1c score at diagnosis was lower in youth who where successful on lifestlye monotherapy compared with those who were not successful.

CONCLUSIONS:

A significant proportion of youth newly diagnosed with T2DM presenting with an HbA_1c <9% effectively achieved/maintained target glycemic control with lifestyle recommendations alone for 12 months.     

Care delivery and outcomes among Belgian children and adolescents with type 1 diabetes

We aimed to investigate care processes and outcomes among children and adolescents with type 1 diabetes treated in hospital-based multidisciplinary paediatric diabetes centres. Our retrospective cross-sectional study among 12 Belgian centres included data from 974 patients with type 1 diabetes, aged 0–18?years. Questionnaires were used to collect data on demographic and clinical characteristics, as well as process of care completion and outcomes of care in 2008. Most patients lived with both biological or adoption parents (77?%) and had at least one parent of Belgian origin (78?%). Nearly all patients (≥95?%) underwent determination of HbA_1c and BMI. Screening for retinopathy (55?%) and microalbuminuria (73?%) was less frequent, but rates increased with age and diabetes duration. Median HbA_1c was 61?mmol/mol (7.7?%) [interquartile range 54–68?mmol/mol (7.1–8.4?%)] and increased with age and insulin dose. HbA_1c was higher among patients on insulin pump therapy. Median HbA_1c significantly differed between centres [from 56?mmol/mol (7.3?%) to 66?mmol/mol (8.2?%)]. Incidence of severe hypoglycaemia was 30 per 100 patient-years. Admissions for ketoacidosis had a rate of 3.2 per 100 patient-years. Patients not living with both biological or adoption parents had higher HbA_1c and more admissions for ketoacidosis. Parents' country of origin was not associated with processes and outcomes of care. Conclusion: Outcomes of care ranked well compared to other European countries, while complication screening rates were intermediate. The observed centre variation in HbA_1c remained unexplained. Outcomes were associated with family structure, highlighting the continuing need for strategies to cope with this emerging challenge.     

Follow‐up results on monitoring and discussing health‐related quality of life in adolescent diabetes care: benefits do not sustain in routine practice

de Wit M, Delemarre‐Van de Waal HA, Bokma JA, Haasnoot K, Houdijk MC, Gemke RJ, Snoek FJ. Follow‐up results on monitoring and discussing health‐related quality of life in adolescent diabetes care: benefits do not sustain in routine practice. Objective: We previously demonstrated that adding monitoring and discussion of health‐related quality of life (HRQoL) of adolescents with type 1 diabetes to routine periodic consultations positively impacts psychosocial well‐being and satisfaction with care. The current study examines whether these positive effects are maintained 1 year after the intervention was terminated and patients received regular care again, with no formal HRQoL assessment. Patients and methods: Forty‐one adolescents with type 1 diabetes were followed for 1 year after the initial HRQoL intervention, in which their HRQoL had been assessed and discussed as part of period consultations using the PedsQL. Changes in physical and psychosocial well‐being [Child Health Questionnaire‐Child Form 87 (CHQ‐CF87), diabetes family conflict scale (DFCS), Center for Epidemiological Studies scale for Depression (CES‐D)], satisfaction with care [Patients' Evaluation of the Quality of Diabetes (PEQ‐D) care], and glycemic control (HbA_1c) were determined 12 months after the HRQoL intervention had ended. Results: One year after the HRQoL intervention, mean scores on CHQ subscales: behavior (p = 0.001), mental health (p = 0.004), and self‐esteem (p < 0.001) had decreased, whereas the family activities subscale remained stable. Adolescents were less satisfied with their care (p = 0.012), and HbA_1c values had increased significantly 12 months postintervention (p = 0.002). Conclusions: The beneficial effects of an office‐based HRQoL intervention in adolescents with diabetes largely disappear 1 year after withdrawing the HRQoL assessment procedure. This finding underscores the importance of integrating standardized evaluation and discussion of HRQoL in routine care for adolescents with diabetes.     

Do high blood glucose peaks contribute to higher HbA<Subscript>1c</Subscript>? Results from repeated continuous glucose measurements in children

Background  HbA_1c levels are infl uenced by the glycemic control of previous 2–3 months. Sometimes patients have surprisingly low HbA_1c in spite of many correctly measured high blood glucose values, which is diffi cult to explain. As glucose sensors give an objective picture based on glucose readings several times per minute over 24 hours, we used the area under the curve (AUC) of such subcutaneous glucose profi les to evaluate their relationship with HbA_1c. Methods  Thirty-two patients were randomized into two study arms, one open and the other blinded. Both arms had 8 pump users and 8 patients with multiple daily injections (MDI). After three months the two arms crossed over. Both study arms wore a continuous glucose monitoring system (CGMS) for 3 days every 2 weeks. HbA_1c was determined before and after each 3-month study period. Results  There was no relationship between HbA_1c and s.c. glucose AUC or between HbA_1c and the number of peaks >15.0 mmol/L when all CGMS profi les during the 6 months were taken together. Children on MDI showed a positive relationship between HbA_1c and AUC (P<0.01) as well as the number of peaks (P<0.01). Children with a negative relationship between HbA_1c and AUC generally had fewer fluctuations in blood glucose values, whereas children with a positive relationship had wide fluctuations. Conclusions  Although there was no relationship between s.c. glucose AUC and HbA_1c, the results indicate that wide blood glucose fluctuations may be related to high HbA_1c values. Therefore, complications and therapeutic interventions should aim at reducing such fluctuations.     

Predictors of glycemic control in the first year of diagnosis of childhood onset type 1 diabetes: A systematic review of quantitative evidence

Early glycemic control is associated with reduced future vascular complications risk in type 1 diabetes (T1D). The aim of this study was to systematically review evidence on the predictors of glycemic control within 12 months of diagnosis of childhood onset T1D. Inclusion criteria for the electronic search were: interventional and observational studies that assessed and quantified an association between the predictor and glycemic control within 12 months of diagnosis of childhood onset T1D. A total of 17 915 articles were identified from 6 databases and 20 studies were finally included in the analysis. Harvest plots and narrative synthesis were used to summarize data from intervention (n = 0), prospective/retrospective cohort (n = 15), and cross‐sectional (n = 5) studies. Significant predictors of poorer glycemic control 0 to 3 months after diagnosis were older age and female gender. Non‐white ethnicity, diabetes autoantibody positivity, measures of deprivation, and non‐private health insurance were potential predictors. Predictors of poorer glycemic control 4 to 12 months after diagnosis were: older age, non‐white ethnicity, a single parent family, high hemoglobin A1c (HbA1c) levels at diagnosis, longer T1D duration, and non‐intensive insulin therapy. Potential predictors included: family with health issues, clinical factors, and comorbidities at diagnosis. Most significant predictors of poor glycemic control within 12 months of diagnosis of childhood onset T1D are non‐modifiable. These factors need to be recognized and addressed through individualized and multidisciplinary diabetes care. Further research is required to confirm the association of potential predictors with early glycemic control.     

Diabetes care provision and glycaemic control in Northern Ireland: a UK regional audit

Aims: To assess the care received, compared to national guidelines, and to investigate factors associated with glycaemic control in children and adolescents with type 1 diabetes attending clinics in Northern Ireland. Methods: An audit of the care provided to all patients attending 11 paediatric diabetes clinics commenced in 2002. A research nurse interviewed 914 patients completing a questionnaire recording characteristics, social circumstances, and aspects of diabetes management, including the monitoring of complications and access to members of the diabetes team. Glycaemic control was measured by glycosylated haemoglobin (HbA_1c), determined at a DCCT aligned central laboratory. Results: The average HbA_1c concentration was 8.8% (SD 1.5%), with 20% of patients achieving recommended HbA_1c levels of less than 7.5%. In the year prior to the audit, 76% of patients were reviewed by a diabetes specialist nurse and 42% were tested for microalbuminuria. After adjustment for confounding factors, better glycaemic control was identified, particularly in patients who had attended exactly four diabetes clinics in the previous year, were members of the patient association Diabetes UK, and lived with both natural parents. Conclusions: In Northern Ireland only a minority of patients achieved recommended HbA_1c levels. Furthermore, children and adolescents with diabetes were reviewed by fewer specialists and were less intensively monitored for microvascular complications than recommended. There was evidence of better control in children who were members of Diabetes UK, suggesting that parental attitude and involvement could lead to benefits.     

Continuous subcutaneous insulin infusion versus multiple daily injections for type 1 diabetes

To review the literature on continuous subcutaneous insulin infusion (CSII) and multiple daily injections (MDI) to help the family of a 13‐year‐old girl with type 1 diabetes mellitus on MDI choose the best insulin delivery method for her to improve her glycaemic control. A literature search was performed to assess available evidence regarding CSII use versus MDI use for glycaemic control. We identified 15 relevant articles and present these, with a detailed analysis of a multicentre randomised controlled trial by Mueller‐Godeffroy et al. Although CSII use demonstrated a reduction in HbA_1c (?0.18 to ?0.7%) in some studies compared to MDI, this finding was not consistent across all studies. Mueller‐Godeffroy et al. did not find a statistically significant different in HbA_1c between CSII and MDI patients; however, additional benefits of insulin pump therapy, including improved diabetes‐related quality of life and reduced care giver burden, were reported. Further high‐quality randomised controlled trials and long‐term data are required to assess the benefits of CSII over MDI and the longevity of these methods.     

Hemoglobin A1c and fructosamine correlate in a patient with sickle cell disease and diabetes on chronic transfusion therapy

In patients with sickle cell disease (SCD) and diabetes mellitus (DM), hemoglobin A_1c (HbA_1c) is unreliable and the American Diabetes Association recommends monitoring long‐term glycemia by measuring serum glucose, but use of serum fructosamine (SF), a measurement independent of red cell lifespan, has been reported. SF as a screen for DM in SCD, however, is not standardized and its relationship to serum glucose has not been validated. Further, screening for DM was not adequately addressed in the 2014 National Heart, Lung, and Blood Institute (NHLBI) guidelines for SCD management. Blood transfusions, an important treatment for some patients with SCD, can also impact HbA_1c. We present a case of a patient with SCD and cystic fibrosis‐related diabetes on monthly chronic transfusions therapy (CTT) who had well‐correlated “steady state” HbA_1c and SF levels over time, suggesting for the first time these markers may actually be useful when following long‐term glycemic control in patients with SCD on CTT programs.     

Disparities in Pediatric Provider Availability by Insurance Type After the ACA in California

Objective

To examine insurance-based disparities in provider-related barriers to care among children in California in the wake of changes to the insurance market resulting from the Affordable Care Act.

Glycemic control in diabetic children: role of mother’s knowledge and socioeconomic status

The aim of this study is to investigate the role of mother’s knowledge and socioeconomic status (SES) of the family on glycemic control in diabetic children. Our sample was taken from successive admissions to the outpatient’s diabetes clinics in Tuzla, Bosnia and Herzegovina. Diabetes knowledge was assessed using the Michigan Diabetes Research and Training Center Diabetes Knowledge Test. Glycemic control was assessed by glycosylated hemoglobin (HbA_1C). The mother’s demographics were obtained by self-report. To categorize families’ SES, parents’ level of education, and current employment were recorded and analyzed using the Hollingshed two-factor index of social position. As expected, higher mother’s knowledge was significantly associated with lower HbA_1C (r = −0.2861705, p = 0.0442). Also, a significant correlation was found between the families’ SES and HbA_1C levels (r = 0.4401921; p = 0.0015). Mothers with more knowledge have children with better metabolic control, and low SES is significantly associated with higher levels of HbA1c. Improvement of mothers’ knowledge and family SES may improve glycemic control and ultimately decrease acute and chronic complications of diabetes in children.     

Insulin dependent diabetes in pregnancy: Impact of maternal blood glucose control on the offspring

Definition of optimal glycaemic control in diabetic pregnancy may still be debated. Measures of glucose control (based on 4–6 daily glucose and frequent HbA_1c values) were recorded in two series of diabetic pregnancies; one multicentre study (n= 92, 1979–82), and one study from our own institution (n= 113, 1983–85). The average pregnancy glucose levels were 5.9 mmol/L (third trimester only) and 6.5 mmol/L (all trimesters), respectively. Discriminant analysis (including pregnancy glucose, HbA_1c, gestational age, diabetes duration and hypertension) revealed that gestational age only (first series) and gestational age and HbA_1c independently of each other (second series) were significantly associated with the occurrence of severe neonatal morbidity present among 30 and 16.8% of the infants, respectively. The overall outcome was favourable. The findings of no perinatal mortality, normal premature delivery rate (8.9%) and a very low rate of severe maternal hypoglycaemia (4.4%) in series two support the feasibility of a strict but individualized management programme.     

Mental Health Beliefs and Barriers to Accessing Mental Health Services in Youth Aging out of Foster Care

ObjectiveTo examine the perspectives of youth on factors that influence mental health service use after aging out of foster care.MethodsFocus groups were conducted with youth with a history of mental health needs and previous service use who had aged out of foster care. Questions were informed by the Health Belief Model and addressed 4 domains: youth perceptions of the “threat of mental health problems,” treatment benefits versus barriers to accessing mental health services, self-efficacy, and “cues to action.” Data were analyzed using a modified grounded-theory approach.ResultsYouth (N = 28) reported ongoing mental health problems affecting their functioning; however, they articulated variable levels of reliance on formal mental health treatment versus their own ability to resolve these problems without treatment. Past mental health service experiences influenced whether youth viewed treatment options as beneficial. Youth identified limited self-efficacy and insufficient psychosocial supports “cueing action” during their transition out of foster care. Barriers to accessing mental health services included difficulties obtaining health insurance, finding a mental health provider, scheduling appointments, and transportation.ConclusionsYouths' perceptions of their mental health needs, self-efficacy, psychosocial supports during transition, and access barriers influence mental health service use after aging out of foster care. Results suggest that strategies are needed to 1) help youth and clinicians negotiate shared understanding of mental health treatment needs and options, 2) incorporate mental health into transition planning, and 3) address insurance and other systemic barriers to accessing mental health services after aging out of foster care.     

Living with type 1 diabetes mellitus: How does the condition affect children's and adolescents’ quality of life?

ObjectiveOur study aimed to measure the health-related quality of life (QoL) of Tunisian children and adolescents with type 1 diabetes mellitus (T1MD).MethodsThis cross-sectional study included 48 patients aged 3–18 years with T1MD, diagnosed for at least 6 months, and their parents, who underwent outpatient examinations from September to December 2018. The children's QoL was assessed using the PedQL 3.0 Diabetes Module exploring five dimensions: diabetes symptoms, treatment barriers, treatment adherence, worry, and communication problems. Parents shared their perception of their children's QoL through the PedQL 4.0 parents’ report (general health and emotional, social, and scholar functioning). Glycemic control was assessed using the last glycated haemoglobin (HbA_1c) values.ResultsThe patients’ average QoL score was 80.52 (± 13.61) without significant differences between gender and age. The longer the duration of the disease, the worse the glycemic control. Girls and adolescents seemed to have poorer glycemic control. Boys and adolescents had more difficulties in all aspects of QoL. Parents perceived a worse QoL than that reported by their sons/daughters (72.34 ± 16.42; P = 0.006).ConclusionThese findings emphasize the importance of an interdisciplinary, biopsychosocial, and family-centered care approach to patients with T1MD.     

Integrating Mental Health Services in Primary Care Continuity Clinics: A National CORNET Study

ObjectiveTo determine whether pediatric continuity clinics integrate mental health (MH) services into care delivery; and to determine whether the level of MH integration is related to access to MH services, types of MH screening performed, self-efficacy, satisfaction with referral sites, and communication with the primary care provider.MethodsPediatric Residency Integrated Survey of Mental Health in Primary Care (PRISM_PC) is a newly designed cross-sectional, Web-based survey of continuity clinic directors participating in a national network of pediatric continuity clinics (CORNET). Definitions of MH models included integrated or nonintegrated MH models or traditional care. The survey included questions regarding access, screening that was performed at sites, comfort with MH management as well as provider satisfaction and communication with referral sites.ResultsSeventy-eight percent (57 of 73) of CORNET site directors responded, representing input from 30% of US pediatric residency continuity programs. Thirty-five percent (n = 20) reported an integrated MH model while 65% (n = 37) reported a nonintegrated MH model. Seventy-nine percent screened for attention-deficit/hyperactivity disorder, 44% for behavioral-emotional issues, and 19% for pediatric depression. No differences were found in terms of screening or tools used on the basis of the level of MH integration. Those with integrated programs were more likely to have access to an on-site psychologist (P = .001) or psychiatrist (P = .006).ConclusionsDirectors from one-third of training programs surveyed reported some level of MH integration in their primary care teaching clinics. Future studies are needed to compare patient and resident education outcomes between integrated and nonintegrated sites.     

Influence of plasma glucagon levels on glycemic control in children with type 1 diabetes

Objective: The aim of this study was to investigate the association between plasma glucose (PG), HbA1c and plasma glucagons levels in children with type 1 diabetes to determine the influence of plasma glucagon on their glycemic control. Methods: The study was conducted in 60 Japanese children, aged 13.3 ± 4.6 years, with type 1 diabetes for at least 3 years of diabetes. Most of the subjects had absent pancreatic β‐cell function. We compared the glucagon levels among patient groups stratified according to the 2‐hour postprandial levels (<50, 50–99, 100–199, 200–299, and ≥300 mg/dL), and the HbA1c levels (<7.0, 7.0–7.9, 8.0–8.9, and ≥9%). Results: The mean 2‐hour postprandial PG, HbA1c and plasma glucagon levels were 174 ± 97 mg/dL, 7.7 ± 1.3% and 84.0 ± 32.6 pg/mL, respectively. The glucagon levels were highly correlated with the PG levels (r = 0.553, P < 0.0001) and mildly correlated with the HbA1c levels (r = 0.301, P = 0.0192). Patients with high PG levels had significantly higher levels of glucagon as compared with those with lower PG levels (139.4 ± 47.2, 78.4 ± 17.3, 82.4 ± 21.0, 98.3 ± 29.2 and 93.8 ± 18.3 pg/mL, P = 0.0009). On the other hand, there were no significant differences in plasma glucagon levels among patient groups stratified according to HbA1c levels (P = 0.1566), however, patients with HbA1c levels ≥ 9% had significantly higher levels of glucagon than those with HbA1c levels < 7% (113.3 ± 53.4 vs 80.8 ± 18.4 pg/mL, P = 0.0291). Conclusion: These results suggest that patients with high PG are likely to have high concentrations of plasma glucagon, which may aggravate glycemic control progressively, leading to elevation of HbA1c levels.     

The Effects of Health Insurance and a Usual Source of Care on a Child’s Receipt of Health Care

IntroductionAlthough recent health care reforms will expand insurance coverage for U.S. children, disparities regarding access to pediatric care persist, even among the insured. We investigated the separate and combined effects of having health insurance and a usual source of care (USC) on children’s receipt of health care services.MethodsWe conducted secondary analysis of the nationally representative 2002-2007 Medical Expenditure Panel Survey data from children (≤ 18 years of age) who had at least one health care visit and needed any additional care, tests, or treatment in the preceding year (n = 20,817).ResultsApproximately 88.1% of the study population had both a USC and insurance; 1.1% had neither one; 7.6% had a USC only, and 3.2% had insurance only. Children with both insurance and a USC had the fewest unmet needs. Among insured children, those with no USC had higher rates of unmet needs than did those with a USC.DiscussionExpansions in health insurance are essential; however, it is also important for every child to have a USC. New models of practice could help to concurrently achieve these goals.     

Health literacy and disease-specific knowledge of caregivers for children with sickle cell disease

This study was conducted to measure the health literacy (HL) and disease-specific knowledge (DSK) of caregivers for children with sickle cell disease (SCD) and relate them to their child's health care utilization. The authors conducted a cross-sectional study of caregiver-child dyads attending an urban pediatric sickle cell clinic. Caregivers were administered the Shortened Test of Functional Health Literacy (S-TOFHLA) and a locally developed DSK questionnaire. Retrospective review of the child's electronic medical record (EMR) was performed to determine annual emergency department (ED) visits and hospitalizations. A total of 142 caregiver-child dyads were recruited for the study. Less than 5% of caregivers had limited HL, with less education (P =.03) and primary language other than English (P =.04) being the only risk factors. Although caregiver HL was not associated with ED visits or hospitalizations, surprisingly DSK was. Caregivers with higher DSK scores had children with higher annual rates of ED utilization (P =.002) and hospitalizations (P =.001), and these children were also more likely to be classified as high ED utilizers (≥4 visits per year; P =.01). Further, caregiver adherence to medication and clinic visits was associated with their child's age (P =.01). Although HL and DSK are both constructs that measure basic health understanding, they differently affect caregivers' ability to navigate and understand the health care system of children with chronic illnesses. This study suggests that the DSK/health care utilization relationship may be a more important measure than HL for programs following children with sickle cell disease and could also have applications in other pediatric chronic diseases.     

Community Health Centers: Medical Homes for Children?

ObjectiveTo explore medical home attributes of community health centers (CHCs) that provide care to low-income children nationwide compared to other providers for the poor.MethodsCross-sectional study of children aged 0 to 17 years in the Medical Expenditure Panel Survey (MEPS; 2003 to 2009) who resided in families living at <200% of the federal poverty level (FPL) and had visits to a primary care setting. CHC visits were defined as a visit to a neighborhood/family health center, rural health clinic, or community health center. Independent measures included provider type, age, gender, race/ethnicity, insurance, FPL, number of parents at home, language, maternal education, health status, and special health care need. Dependent measures included 4 medical home attributes: accessibility, and family-centered, comprehensive, and compassionate care.ResultsCHCs typically serve low-income children who are publicly insured or uninsured, come from racial/ethnic minority groups, and have poorer health status. Eighty percent to 90% of parents visiting both CHCs and other primary care providers rated high levels of family-centered, comprehensive, and compassionate care. However, CHCs had a 10% to 18% lower rating of accessibility (after-hours care, telephone access) even after controlling for sociodemographic characteristics. Racial/ethnic disparities existed at both settings, but these patterns did not differ between CHCs and other settings.ConclusionsOn the basis of parental reports, CHCs received similar ratings to other primary care providers for family-centered, comprehensive, and compassionate care, but lower ratings for accessibility. Further studies should examine strategies for practice transformation in CHCs to improve patient satisfaction and accessibility to optimize child health outcomes.     

Re-hospitalization after diagnosis of diabetes varies by gender and socioeconomic status in urban African-American and Latino young people

Abstract: Purpose: To examine risk factors for re‐hospitalization after diagnosis of diabetes mellitus amongst urban minority children. Methods: Families of insulin‐treated African‐American and Latino patients aged < 18 yr at diagnosis (n = 216) were interviewed about sociodemographics and other characteristics, on average 5.9 yr after diagnosis. Results and conclusions: About 60% of respondents were re‐hospitalized at least once for diabetes‐related reasons (n = 128). Half of those questioned had Medicaid or no health insurance at all; 23% fit criteria for a non‐autoimmune, type 2 diabetic phenotype. Those who avoided re‐hospitalization were more likely to have been seen initially at a tertiary care facility, to have private health insurance, and to be males. They had, on average, 2 yr shorter duration of diabetes at the time of interview. Risk for re‐hospitalization was not associated with age at diagnosis, ethnicity, diabetic phenotype, or source of care during the past year. In multivariate analysis, predictors of re‐hospitalization were gender [odds ratio (OR) 1.98 for females vs. males (95% confidence interval (CI) = 1.05–3.72)], duration of diabetes [OR = 1.46 per yr (95% CI = 1.36–1.57)], initial ascertainment at a community hospital [OR = 5.44 vs. tertiary care facility (95% CI = 2.61–11.29)] and having Medicaid or no insurance [OR = 2.73 (95% CI = 1.42–5.24)], compared with those with another type of health insurance. There is a high risk of re‐hospitalization after the initial diagnosis of diabetes among insulin‐treated minority children, particularly the uninsured and those on Medicaid, in part related to duration of disease and where the initial treatment occurred.