How Do the Challenges of Emerging Adulthood Inform our Understanding of Diabetes Distress? An Integrative Review.

PURPOSE OF REVIEW: Emerging adulthood (ages 18-29) presents many emotional, social, and developmental challenges that can contribute to an increased sense of burden when managing type 1 diabetes (T1D). Diabetes distress (DD) is the concept that captures the emotional burden, frustrations, and worries resulting from living with T1D. This integrative review sets out to examine the impact of developmental context by answering this question: How do the challenges of emerging adulthood inform our understanding of DD? RECENT FINDINGS: DD is highly prevalent in emerging adults and occurs at higher rates than in other age groups. Qualitative studies reveal that DD is embedded within the developmental challenges specific to living with T1D during this stage. Quantitative studies reveal the prevalence and correlates of DD in this age group, and qualitative studies augment these findings by capturing the scope and complexity of the emotional burden of living with T1D as an emerging adult.

IMPROVEMENTS IN METABOLIC CONTROL IN ADULTS WITH TYPE 2 DIABETES FOLLOWING REFERRAL TO A DIABETES CENTER, 2005-2010.

OBJECTIVE: We aimed to compare metabolic control in adults with diabetes in the general population to those newly referred to a diabetes center and after 1 year of specialty care. METHODS: We performed a retrospective comparison of adults with diabetes aged ≥20 years data from the National Health and Nutrition Examination Survey (NHANES, n = 1,674) and a diabetes center (n = 3,128) from 2005-2010. NHANES participants represented the civilian, non-institutionalized U.S. POPULATION: Diabetes center referrals lived primarily around eastern Massachusetts. The proportion attaining targets for glycated hemoglobin A1c (A1c), blood pressure (BP), low-density lipoprotein (LDL) cholesterol, or all 3 (ABC control) and the proportion prescribed medications to lower A1c, BP, or cholesterol were evaluated. RESULTS: Compared to the general sample, a smaller proportion of new diabetes center referrals had A1c <7% (<53 mmol/mol, 24% vs. 53%, P<.001), BP <130/80 mm Hg (38% vs. 50%, P<.001), and ABC control (5.6% vs. 17%, P<.001) but not LDL<100 mg/dL (<2.6 mmol/L, 54% vs. 53%, P = .65). After 1 year, more diabetes center referrals attained targets for A1c (40%), BP (38%), LDL (67%), and ABC control (15%) (P<.001 for all versus baseline). ABC control was not different between the general sample and diabetes center referrals at 1 year (P = .16). After 1 year, a greater percentage of diabetes center referrals compared to the general sample were prescribed medications to lower glucose (95% vs. 72%), BP (79% vs. 64%), and cholesterol (77% vs. 54%)(all P<.001). CONCLUSION: Compared to the general population, glycemic control was significantly worse for adults newly referred to the diabetes center. Within 1 year of specialty care, ABC control increased 270% in the setting of significant therapy escalation. ABBREVIATIONS: A1c = glycated hemoglobin A1c ABC = composite of A1c, blood pressure, and cholesterol ACEi = angiotensin-converting enzyme inhibitor ARB = angiotensin receptor blocker BMI = body mass index BP = blood pressure EHR = electronic health record LDL = low-density lipoprotein NCHS = National Center for Health Statistics NHANES = National Health and Nutrition Examination Survey PCP = primary care provider.

Improving dietary quality in youth with type 1 diabetes: randomized clinical trial of a family-based behavioral intervention.

BACKGROUND: Diets of children with type 1 diabetes are low in fruits, vegetables, and whole grains, and high in foods of minimal nutritional value, increasing risk for future adverse health outcomes. This 18-month randomized clinical trial tested the effect of a family-based behavioral intervention integrating motivational interviewing, active learning, and applied problem-solving on the primary outcomes of dietary intake and glycemic control among youth with type 1 diabetes. METHODS: A parallel-group study with equal randomization was conducted at an outpatient, free-standing, multidisciplinary tertiary diabetes center in the United States. Eligible youth were those age 8-16 years with type 1 diabetes diagnosis ≥1 year and hemoglobin A1c (HbA1c) ≥6.5% and ≤10.0%. Participants were 136 parent-youth dyads (treatment n = 66, control n = 70). The intervention consisted of 9 in-clinic sessions delivered to the child and parent; control condition comprised equivalent assessments and number of contacts without dietary advice. Dietary intake was assessed using 3-day diet records at 6 time points across the 18-month study. Dietary outcomes included the Healthy Eating Index-2005 (HEI2005; index measuring conformance to the 2005 United States Dietary Guidelines for Americans) and Whole Plant Food Density (WPFD; number of cup or ounce equivalents per 1000 kcal of whole grains, whole fruit, vegetables, legumes, nuts, and seeds consumed). HbA1c was obtained every 3 months. Overall comparison of outcome variables between intervention and usual care groups was conducted using permutation tests. RESULTS: There was a positive intervention effect across the study duration for HEI2005 (p = .015) and WPFD (p = .004). At 18 months, HEI2005 was 7.2 greater (mean ± SE 64.6 ± 2.0 versus 57.4 ± 1.6), and WPFD was 0.5 greater (2.2 ± 0.1 versus 1.7 ± 0.1) in the intervention group versus control. There was no difference between groups in HbA1c across the study duration. CONCLUSIONS: This behavioral nutrition intervention improved dietary quality among youth with type 1 diabetes, but did not impact glycemic control. Findings indicate the potential utility of incorporating such strategies into clinical care, and suggest that improvement in diet quality can be achieved in families living with this burdensome disease. TRIAL REGISTRATION: Clinicaltrials.gov registration number: NCT00999375.

Care utilization in a pediatric diabetes clinic: cancellations, parental attendance, and mental health appointments.

OBJECTIVE: To examine care utilization, family attendance, and hemoglobin A1c levels in a multidisciplinary pediatric diabetes clinic. STUDY DESIGN: This retrospective electronic record review of deidentified data included patients (99% with type 1 diabetes) with established diabetes care, aged <30 years (mean age, 15 ± 5.2 years), and duration of diabetes >1 year (mean 8.5 ± 5.1 years) at first visit during a 2-year period. Outcomes included care utilization, family attendance, and glycemic control, as indicated by hemoglobin A1c level. Analyses included t tests, ANOVA, χ2 tests, ORs and 95% CIs, and multivariate analyses. RESULTS: The study cohort comprised 1771 patients, with a mean of 5.8 ± 2.8 visits per patient. Roughly 15% of the scheduled appointments resulted in a cancellation or no-show; 61% of patients missed ≥1 visit. Patients with ≥2 missed appointments had higher A1c values and were older than those with <2 missed visits. Almost one-half of visits were attended by mothers alone; fathers attended 22% of visits. Patients whose fathers attended ≥1 visit had lower A1c values than patients whose fathers never attended. Eighteen percent of patients had onsite mental health visits. Patients with ≥1 mental health visit had higher mean A1c values, shorter duration of diabetes, and were younger compared with those with no mental health visits. CONCLUSION: Our observations suggest the need to encourage attendance at diabetes visits and to include fathers to improve A1c values. The high rate of missed visits, especially in patients with poor glycemic control, identifies wasted provider effort when late cancellations/no-shows result in vacant clinic time. It is important to explore reasons for missed visits and to identify approaches to maximizing attendance, such as extended evening/weekend clinic hours and virtual visits.

Transition to self-management among emerging adults with type 1 diabetes: a mixed methods study.

Introduction: Emerging adulthood is challenging for young people with type 1 diabetes (T1D). This study evaluated transition to diabetes self-management and perceptions of care transfer using mixed methods. Methods: An online survey queried demographics, management characteristics, diabetes knowledge, self-care readiness, adherence, and diabetes distress. T-tests compared survey scores between those with self-reported target A1c <7.0% versus ≥7.0%. Pearson correlations assessed associations between A1c and diabetes distress, stratified by A1c <7.0% versus ≥7.0%. Qualitative semi-structured interviews elicited perceptions of young adults; transcripts were analyzed using directed qualitative content analysis. Results: Of 141 participants (30% male, 84% non-Hispanic white) completing the survey, 41% self-reported target A1c <7.0%. Diabetes knowledge and self-care readiness scores did not differ between those with A1c <7.0% versus ≥7.0%, while diabetes distress was lower (45 ± 20 vs 52 ± 20, p=0.01) and adherence higher (77 ± 12 vs 71 ± 14, p=0.02) in those with A1c <7.0% versus ≥7.0%. Diabetes distress was significantly associated with glycemic outcomes in those reporting A1c ≥7.0% (R=0.36, p<0.01). Qualitative analysis (24 participants) revealed five themes and two sub-themes, notable for need for more mental health support, support from others with T1D, benefits of technology for care autonomy, and challenges of obtaining diabetes supplies. Discussion: Emerging adults with self-reported target A1c endorsed lower diabetes distress and higher adherence than those with elevated A1c. Mental health access, support from others with T1D, technology use, and guidance for supply acquisition may improve transition to self-management and care transfer for emerging adults with T1D.

Technology to optimize pediatric diabetes management and outcomes.

Technology for diabetes management is rapidly developing and changing. With each new development, there are numerous factors to consider, including medical benefits, impact on quality of life, ease of use, and barriers to use. It is also important to consider the interaction between developmental stage and technology. This review considers a number of newer diabetes-related technologies and explores issues related to their use in the pediatric diabetes population (including young adults), with a focus on psychosocial factors. Areas include trend technology in blood glucose monitoring, continuous glucose monitoring, sensor-augmented insulin pumps and low glucose suspend functions, internet applications including videoconferencing, mobile applications (apps), text messaging, and online gaming.

Relationships among parent and youth healthful eating attitudes and youth dietary intake in a cross-sectional study of youth with type 1 diabetes.

BACKGROUND: Constructs based on Social Cognitive Theory have shown utility in understanding dietary behavior; however, little research has examined these relations in youth and parents concurrently. Unique demands of dietary management among families of youth with type 1 diabetes (T1D) suggest the importance of investigation in this population. The purpose of this study was to develop and evaluate youth and parent measures of self-efficacy, outcome expectations, and barriers for healthful eating, and parent modeling of healthful eating, in a sample of youth with type 1 diabetes and their parents. METHODS: Youth (n=252) ages 8-18 years with diabetes duration ≥1 year and parents completed self-report measures of healthful eating attitudes including self-efficacy, perceived barriers, positive and negative outcome expectations; youth reported parent modeling of healthful eating. Youth dietary intake from 3-day diet records was used to calculate the Healthy Eating Index 2005 and the Nutrient Rich Foods 9.3 index, measures of overall diet quality. The relations among parent and youth healthful eating attitudes, parent modeling, and youth diet quality were examined using structural equation modeling. RESULTS: Internal consistency and test-retest reliability of the measures were acceptable. The structural equation model demonstrated acceptable fit (CFI/TLI=0.94/0.94; RMSEA=0.03), and items loaded the hypothesized factors. Parent modeling ß^=.27,p=.02 and attitudes toward healthful eating (latent variable comprised of self-efficacy, barriers, outcome expectations) ß^=.16,p=.04 had direct effects on youth diet quality. Parent modeling had a direct effect on youth attitudes ß^=.49,p<.001; parent attitudes had an indirect effect on youth attitudes through parent modeling ß^=.12,p,<.001. Youth attitudes were not associated with youth diet quality. Overall, the model accounted for 20% of the variance in child diet quality. CONCLUSIONS: Parent diet-related behaviors demonstrated an impact on youth attitudes and diet quality, suggesting the importance of family-based clinical and public health efforts to improve diet.

New-Onset Type 1 Diabetes in a Child With Diabetic Ketoacidosis and Severe Hypertriglyceridemia Without Pancreatitis.

Hypertriglyceridemia is a complication of diabetic ketoacidosis (DKA) secondary to insulin deficiency inhibiting lipoprotein lipase and increasing lipolysis, but it is rare in children. A 7-year-old boy with history of autism spectrum disorder (ASD) presented with abdominal pain, vomiting, and "heavy breathing." Initial laboratory tests revealed pH 6.87 and glucose 385 mg/dL (21.4 mmol/L), consistent with new-onset diabetes and DKA. His blood appeared lipemic; triglycerides were 17 675 mg/dL (199.6 mmol/L) with normal lipase (10 units/L). He received intravenous insulin and DKA resolved within 24 hours. Insulin infusion continued through day 6 for management of hypertriglyceridemia; triglycerides decreased to 1290 mg/dL (14.6 mmol/L) during this period. He never developed pancreatitis (lipase peaked at 68 units/L) or required plasmapheresis. With his ASD history, he had a restrictive diet high in saturated fat, which included up to 30 breakfast sausages daily. His triglycerides normalized after discharge. Severe hypertriglyceridemia can complicate DKA in newly diagnosed type 1 diabetes (T1D). Hypertriglyceridemia can be safely managed with insulin infusion in the absence of end-organ dysfunction. This complication should be considered in patients with DKA at diagnosis of T1D.

Transition to adult care for youth with type 1 diabetes.

Emerging adults with type 1 diabetes are at risk for poor glycemic control, gaps in medical care, and adverse health outcomes. With the increasing incidence in type 1 diabetes in the pediatric population, there will be an increase in the numbers of teens and young adults transferring their care from pediatric providers to adult diabetes services in the future. In recent years, the topic of transitioning pediatric patients with type 1 diabetes to adult diabetes care has been discussed at length in the literature and there have been many observational studies. However, there are few interventional studies and, to date, no randomized clinical trials. This paper discusses the rationale for studying this important area. We review both observational and interventional literature over the past several years, with a focus on new research. In addition, important areas for future research are outlined.

"Fear That One Day I May Not Be Able to Afford Insulin": The Emotional Burden of Diabetes Costs During Emerging Adulthood.

Emerging adults (EAs) with type 1 diabetes (T1D) often experience challenges in diabetes management, in particular transitioning to financial independence. EAs 18-30 years of age with T1D completed online surveys about diabetes distress and an open-ended query about the most important worry among survey questions. Most of the 287 respondents (89.5%) endorsed "Agree" or "Somewhat agree" to the statement "I worry about the cost of diabetes." Responses did not differ by gender, age, diabetes duration, race/ethnicity, diabetes technology use, student status, income, or insurance status. However, a greater proportion of those not endorsing cost as a substantial burden achieved A1c <7% (92.9%) versus those who were neutral (46.2%) or who endorsed cost as a burden (50.6%) (P = 0.004). Furthermore, in open-ended responses, cost was the most frequently noted worry. Diabetes costs are a major concern for EAs, likely contributing to diabetes distress during this developmental stage, and clinicians should consider discussing diabetes costs with this population.

Assessing Diabetes Distress in Emerging Adults With Type 1 Diabetes: Development and Validation of the Problem Areas in Diabetes-Emerging Adult Version.

OBJECTIVES: Emerging adults (18 to 30 years of age) with type 1 diabetes experience suboptimal glycemic and psychological outcomes compared with other groups. The emotional burden of the unending self-care needs of diabetes management appears to be related to these poor health outcomes. However, there is no validated measure of this emotional burden in the developmental context of emerging adulthood. The primary aim of this study was to examine the psychometric properties of a new measure of diabetes distress in emerging adults with type 1 diabetes in the United States. METHODS: In this cross-sectional study, emerging adults with type 1 diabetes completed an online survey, including measures of diabetes distress, depressive symptomology and the newly developed measure, the Problem Areas in Diabetes-Emerging Adult version (PAID-EA). Participants also answered demographic and clinical outcomes questions. Internal consistency, reliability, construct validity and the underlying factor structure of the PAID-EA were assessed. RESULTS: Participants (N=287, 78% women) had a median age of 24 years, 43% were full-time students, 78% wore an insulin pump and 90% used a continuous glucose monitor. Mean self-reported glycated hemoglobin was 7.1%±1.2%. The PAID-EA demonstrated good internal consistency and reliability (Cronbach alpha=0.89), was composed of 1 component accounting for 29% of the observed variance and demonstrated construct validity as it was significantly correlated with known measures of similar constructs and with glycated hemoglobin levels (ρ=0.20, p=0.001). CONCLUSIONS: The PAID-EA holds promise as a reliable and valid measure of diabetes distress in emerging adults.

Therapeutic play to teach children with type 1 diabetes insulin self-injection: A pilot trial in a developing country.

PURPOSE: Child participation in type 1 diabetes (T1D) self-care is needed in developing countries due to a lack of resources, especially during the school day. This pilot study evaluated the feasibility of a therapeutic play intervention (ITP) versus standard education (SE) on the ability of children with T1D to correctly perform insulin injection technique. DESIGN AND METHODS: Children with T1D (7-12 years) were recruited at two diabetes clinics in Brazil and randomized to ITP or SE. Registered nurses received protocol training to deliver the intervention and perform data collection. ITP group received an education that included a story about a child with T1D who self-injects insulin at school; SE group received routine clinic-based education. Preintervention, children were video-recorded giving insulin injections to a doll; postintervention, children were rerecorded giving the doll an injection. The research team reviewed the videos and assessed the injection technique using validated checklists. Parents reported children's self-injection practices at baseline and 30 days. RESULTS: Children (N = 20, 40% male) were 9.6 ± 1.3 years old and had T1D for 3.6 ± 2.3 years; HbA1c was 9.1 ± 2.0%; 20% of ITP and 50% of SE children used syringes (vs. pens) for injections. At baseline, 80% of both groups knew how to self-inject; most were taught by a parent/relative. Injection technique scores were low in both groups; ITP group increased their scores significantly postintervention. Practices of self-injection did not change in either group after 30 days. PRACTICE IMPLICATIONS: The play-based intervention appeared to improve the injection technique in the short-term. Pilot findings support the development of a larger trial to evaluate the effectiveness of ITP on educating children on insulin injections.

Responsibility sharing between adolescents with type 1 diabetes and their caregivers: importance of adolescent perceptions on diabetes management and control.

OBJECTIVE: To analyze associations between factor scores for caregiver responsibility for direct and indirect diabetes management tasks with glycemic control and blood glucose monitoring (BGM) frequency. METHODS: Two hundred and sixty one adolescents with type 1 diabetes and their caregivers completed the Diabetes Family Responsibility Questionnaire (DFRQ). Data on diabetes management (e.g., BGM frequency) and glycemic control (e.g., A1c values) were obtained. RESULTS: Confirmatory factor analysis of the DFRQ revealed two factors-direct and indirect management tasks. Multivariate analyses demonstrated that adolescent perception of greater responsibility sharing with caregivers on direct management tasks was significantly associated with higher BGM frequency. CONCLUSIONS: Adolescents who perceive greater caregiver responsibility, particularly around direct management tasks, engage in better diabetes management. Implications of these findings include designing interventions that encourage and sustain caregiver responsibility through adolescence and make explicit the contribution of caregivers.

Significant vitamin D deficiency in youth with type 1 diabetes mellitus.

Serum 25-hydroxyvitamin D was measured in 128 youth with type 1 diabetes mellitus. Less than 25% of the patients were vitamin D sufficient. Because individuals with type 1 diabetes mellitus possess multiple risk factors for skeletal fragility, ensuring vitamin D sufficiency throughout childhood and adolescence in this population seems especially warranted.

A multisite trial of a clinic-integrated intervention for promoting family management of pediatric type 1 diabetes: feasibility and design.

The feasibility of a family-based clinic-integrated behavioral intervention to improve family management of type 1 diabetes was evaluated. In each of four clinical sites, 30-32 families (a total of 122) were randomized to intervention or usual care comparison groups. The WE*CAN intervention, based on family problem-solving methods, was delivered during three routine clinic visits by trained 'Health Advisors'. Of eligible families across the four sites, 83% agreed to participate, of whom 96% completed the baseline, mid-term, and postintervention assessments. Families participated in an average of 2.85 intervention sessions over an 8-month period. The intervention was integrated into the clinic setting without impairing clinic flow and was implemented with fidelity and consistency across sites by trained non-professionals. The findings provide evidence of the feasibility of conducting a multisite trial to evaluate the effects of a clinic-integrated problem-solving intervention to improve family management. Many lessons were learned that provide guidance for recruitment, measurement, and intervention for the larger clinical trial.

The impact of modifiable family factors on glycemic control among youth with type 1 diabetes.

OBJECTIVE: To identify modifiable family factors impacting glycemic control in youth with type 1 diabetes (T1DM) beyond the anticipated physical, developmental, and behavioral issues associated with adolescence. STUDY DESIGN: In 153 youth (aged 8-16 yr) with T1DM duration of 6.3 +/- 3.5 yr and average hemoglobin A1c (HbA1c) of 8.4 +/- 1.4%, we examined modifiable family factors that might impact adherence to diabetes management and, in turn, influence glycemic control. Youth and parents completed surveys that assessed diabetes-specific knowledge, negative affect related to blood glucose monitoring (BGM), and parental-perceived burden of diabetes care. Clinician report and chart review provided data on growth, pubertal development, and diabetes management tasks. Glycemic control was measured as HbA1c. RESULTS: In bivariate analyses, higher parental diabetes-specific knowledge (p < 0.0001), less youth negative affect related to BGM (p = 0.0005), and less parental-perceived burden (p = 0.0008) were associated with lower HbA1c. In a multivariate model controlling for demographic and diabetes-specific variables, these three factors remained independent and significant predictors of HbA1c (R(2) = 0.31 and p < 0.0001). Higher parental knowledge, less youth negative affect, and less parental burden predicted lower HbA1c, while youth knowledge and parental negative affect did not. CONCLUSION: To attain optimal glycemic control, treatment programs for youth with T1DM should include ongoing efforts to reinforce parental knowledge of diabetes tasks, promote positive youth affect related to diabetes management, and acknowledge and reduce parental-perceived burden of diabetes management.

Automated Insulin Delivery Systems: Hopes and Expectations of Family Members.

BACKGROUND: This study examines the hopes and expectations that children, adolescents, and adults with type 1 diabetes and their families have for new automated insulin delivery systems. The study also aims to examine how the automated insulin delivery system may impact family functioning and individual members' psychosocial adjustment. METHODS: Forty-eight semistructured focus groups (n = 195) and 89 individual interviews were conducted with children, adolescents, and adults with type 1 diabetes and parents and partners. Coders reviewed results in key themes most likely to contain references to the family system. Clusters were analyzed using thematic analysis to identify participants' salient hopes and expectations of how new technology may impact family relationships and individual psychosocial functioning. RESULTS: Three main themes emerged for participants' hopes and expectations for implementation of the automated insulin delivery system. First, there is an expectation that this diabetes technology will alleviate diabetes-specific worry and burden for the people with diabetes and other family members. Second, there is also hope that this system may reduce day-to-day stress and, third, improve family relationships. CONCLUSIONS: The unique perspective of a broad age group provides insight into how individuals and families creatively address the multiple tasks required in daily diabetes management. Study findings elucidate the very high hopes and expectations held by those managing type 1 diabetes and the impact this new technology may have on family relationships. Awareness of these hopes and expectations is important for developers and clinicians in addressing potential challenges to uptake and to ensure that expectations are set appropriately.

Disordered Eating Behaviors Are Not Increased by an Intervention to Improve Diet Quality but Are Associated With Poorer Glycemic Control Among Youth With Type 1 Diabetes.

OBJECTIVE: This study examines whether participation in an 18-month behavioral intervention shown previously to improve overall diet quality inadvertently increases disordered eating behaviors (DEBs) in youth with type 1 diabetes and investigates the association of DEB with multiple measures of glycemic control and variability. RESEARCH DESIGN AND METHODS: Participants reported DEB and diabetes management at baseline and 6, 12, and 18 months; masked continuous glucose monitoring, HbA1c, and 1,5-anhydroglucitol (1,5-AG) were obtained concurrently. Linear mixed models estimated the intervention effect on DEB, the association of DEB with diabetes adherence and measures of glycemic control and variability, and whether DEB modified glycemic trajectories. RESULTS: There was no intervention effect on DEB (P = 0.84). DEB was associated with higher HbA1c (P = 0.001), mean sensor glucose (P = 0.001), and percent sensor glucose values >180 mg/dL (P = <0.001); with lower 1,5-AG (P = 0.01); and with worse diabetes adherence (P = 0.03). DEB was not associated with percent sensor glucose values <70 mg/dL or any measures of glycemic variability. There was a significant DEB × time interaction effect for mean sensor glucose (P = 0.05) and percent sensor glucose values >180 mg/dL (P = 0.04). Participants reporting less DEB had a developmentally expected deterioration in glycemic control throughout the study. Participants reporting more DEB had poor glycemic control at baseline that remained poor throughout the study. CONCLUSIONS: Findings show a potential to improve diet quality without increasing DEB and indicate an association of DEB with persistent hyperglycemia but not hypoglycemia or glycemic variability.

Temporal trends in the treatment of pediatric type 1 diabetes and impact on acute outcomes.

OBJECTIVE: To evaluate temporal trends in pediatric type 1 diabetes (T1DM) management and resultant effects on outcomes. STUDY DESIGN: Two pediatric T1DM cohorts were followed prospectively for 2 years and compared; Cohort 1 (N = 299) was enrolled in 1997 and Cohort 2 (N = 152) was enrolled in 2002. In both cohorts, eligible participants were identified and sequentially approached at regularly scheduled clinic visits until the target number of participants was reached. Main outcome measures were hemoglobin A1c (A1c), body mass index Z score (Z-BMI), and incidence rate (IR; per 100 patient-years) of hypoglycemia, hospitalizations, and emergency room (ER) visits. RESULTS: At baseline, Cohort 2 monitored blood glucose more frequently than Cohort 1 (> or = 4 times/day: 72% vs 39%, P < .001) and was prescribed more intensive therapy than Cohort 1 (> or = 3 injections/day or pump: 85% vs 65%, P < .001). A1c was lower in Cohort 2 than Cohort 1 at baseline (8.4% vs 8.7%, P = .03) and study's end (8.7% vs 9.0%, P = .04). The cohorts did not differ in Z-BMI (0.83 vs 0.79, P = .57) or IR of hospitalizations (11.2 vs 12.9, P = .38). Cohort 2 had lower IR of total severe hypoglycemic events (29.4 vs 55.4, P < .001) and ER visits (22.0 vs 29.3, P = .02). CONCLUSIONS: T1DM management intensified during the 5 years between cohorts and was accompanied by improved A1c and stable Z-BMI. Along with improved control, IR of severe hypoglycemia and ER visits decreased by almost 50% and 25%, respectively.