Diabetes distress and glycaemic control in young adults with type 1 diabetes: Associations by use of insulin pumps and continuous glucose monitors.

AIMS: We determined whether high diabetes distress (DD) in young adults with type 1 diabetes was associated with higher glycated haemoglobin (HbA1c ) levels and whether this association was similar among those who were and were not using diabetes devices (insulin pumps and/or continuous glucose monitors [CGMs]). METHODS: In 2017, an online survey was completed by 423 of 743 (57%) young adults (19-31 years) with type 1 diabetes receiving care at a specialty clinic in New York City. HbA1c level was the primary outcome measure, and high DD (Diabetes Distress Scale score ≥3) was the primary exposure. Associations were adjusted for sociodemographic covariates. RESULTS: Of the 419 respondents with complete DD data, 59% were female and 69% were non-Hispanic white. Both devices (pump and CGM) were used by 35%, either device by 42% and neither device by 24%. The mean (SD) HbA1c was 64 (19) mmol/mol (8.0 [1.7] %) and 24% had high DD. The adjusted mean (95% confidence interval) HbA1c was 10 (6, 14) mmol/mol (0.9 [0.5, 1.2] %) greater in those with high DD than in those without it. This HbA1c difference associated with high DD was similar regardless of device use: 9 (3, 15) mmol/mol (0.8 [0.3, 1.4] %) greater among those using both devices; and 9 (-0.9, 18) mmol/mol (0.8 [-0.1, 1.7] %) greater among those using neither device. CONCLUSIONS: High DD in young adults requires more attention because it is associated with higher HbA1c levels, even among those using insulin pumps and CGMs.

The association between dispositional mindfulness and glycemic control in type 1 diabetes during early adulthood: Differences by age and adverse childhood experiences.

BACKGROUND: The study objective was to determine whether higher levels of dispositional mindfulness were associated with lower HbA1c levels among young adults with type 1 diabetes (T1D) and whether this association differed by age or exposure to adverse childhood experiences (ACEs). METHODS: An online cross-sectional survey, called T1 Flourish, was completed in 2017 by 423 of 743 (56.9%) young adults (19-31 years) with T1D receiving outpatient care at a diabetes specialty clinic in New York City. HbA1c levels were abstracted from medical records. Respondents were categorized by age, high and low dispositional mindfulness (median split on Cognitive and Affective Mindfulness Scale-Revised), and exposure to any of 10 ACEs. RESULTS: Respondents had a mean (SD) HbA1c of 64 (18) mmol/mol [8.0 (1.7)%]; 59.3% were female and 69.4% were non-Hispanic white. The covariate-adjusted association between dispositional mindfulness and HbA1c differed by age group and ACEs. Among 27- to 31-year-olds, those with high mindfulness had HbA1c levels that were 8 mmol/mol [0.7%] lower (95% confidence interval, 2-13 mmol/mol [0.2-1.2%]) than those with low mindfulness, and this association tended to be stronger in those with ≥1 ACEs. Weaker, non-significant associations in the same direction occurred in 23- to 26-year-olds. Among 19- to 22-year-olds, those with high mindfulness and no ACEs tended to have higher HbA1c levels. CONCLUSIONS: In young adults with T1D, higher mindfulness was significantly associated with lower HbA1c only among 27- to 31-year-olds. In early adulthood, the impact of mindfulness-based interventions on glycemic control may vary by age and childhood trauma history.

Financial stress in emerging adults with type 1 diabetes: a mini review integrating lessons from cancer research.

Amongst adults in the United States, those ages 18-30 have the highest unemployment rates, the lowest incomes, and are the most likely to be uninsured. Achieving financial independence is a core developmental task for this age group, but for those with type 1 diabetes (T1D), the high costs of insulin and diabetes supplies as well as an employment-based insurance model with minimal safety net can make this a formidable challenge. Cost-related non-adherence to diabetes management is particularly high in emerging adults with T1D and is associated with severe consequences, such as diabetic ketoacidosis (DKA) and even death. Objective financial burden and subjective financial distress related to illness are not unique to diabetes; in cancer care this construct is termed financial toxicity. Researchers have identified that emerging adults with cancer are particularly vulnerable to financial toxicity. Such research has helped inform models of care for cancer patients to mitigate cost-related stress. This mini review aims to briefly describe the state of the science on financial stress for emerging adults with T1D and explore parallels in cancer scholarship that can help guide future work in diabetes care to reduce health inequity, drive research forward, improve clinical care, and inform policy debates.

Lessons From Insulin: Policy Prescriptions for Affordable Diabetes and Obesity Medications.

Escalating insulin prices have prompted public scrutiny of the practices of drug manufacturers, pharmacy benefit managers, health insurers, and pharmacies involved in production and distribution of medications. As a result, a series of policies have been proposed or enacted to improve insulin affordability and foster greater equity in access. These policies have implications for other diabetes and obesity therapeutics. Recent legislation, at both the state and federal level, has capped insulin out-of-pocket payments for some patients. Other legislation has targeted drug manufacturers directly in requiring rebates on drugs with price increases beyond inflation rates, an approach that may restrain price hikes for existing medications. In addition, government negotiation of drug pricing, a contentious issue, has gained traction, with the Inflation Reduction Act of 2022 permitting limited negotiation for certain high expenditure drugs without generic or biosimilar competition, including some insulin products and other diabetes medications. However, concerns persist that this may inadvertently encourage higher launch prices for new medications. Addressing barriers to competition has also been a priority such as through increased enforcement against anticompetitive practices (e.g., "product hopping") and reduced regulatory requirements for biosimilar development and market entry. A novel approach involves public production, exemplified by California's CalRx program, which aims to provide biosimilar insulins at significantly reduced prices. Achieving affordable and equitable access to insulin and other diabetes and obesity medications requires a multifaceted approach, involving state and federal intervention, ongoing policy evaluation and refinement, and critical examination of corporate influences in health care.

Association of Childhood Family Connection With Flourishing in Young Adulthood Among Those With Type 1 Diabetes.

Importance: Higher levels of childhood family connection have been associated with measures of adult flourishing or eudaimonic well-being, such as purpose, self-acceptance, positive relationships, and growth. However, this association has not been examined among those with childhood-onset chronic disease. Objectives: To investigate whether higher levels of childhood family connection were associated with greater flourishing in young adulthood among those with type 1 diabetes and, secondarily, whether this association was present across levels of adverse childhood experiences and childhood social position. Design, Setting, and Participants: In 2017, the cross-sectional Type 1 Flourish survey was administered to all 743 young adults, aged 18 to 29 years, with type 1 diabetes who had received outpatient care in 2016 at a diabetes specialty clinic in New York, New York. Eligible participants completed the survey online or during clinic visits. Data analyses were conducted in September and October 2019. Exposures: The main exposure was childhood family connection (sample-defined tertiles), based on scores from a 7-item scale assessing parental attention, affection, and communication during childhood. Adverse childhood experiences, childhood social position, and other sociodemographic characteristics were also reported. Recent hemoglobin A1c levels were abstracted from medical records. Main Outcomes and Measures: Flourishing score calculated from the 42-item Psychological Well-being Scale developed by Ryff. Results: The survey was completed by 423 of 743 patients (56.9%), and the analysis included 415 participants (98.1%) with complete data on family connection and flourishing. The mean (SD) age of the sample was 25.0 (3.2) years, with 246 (59.3%) female respondents and 288 (69.6%) non-Hispanic white respondents. The mean (SD) flourishing score was 221.8 (37.7). After adjusting for age, sex, race/ethnicity, education, income, age at type 1 diabetes diagnosis, and hemoglobin A1c level, mean flourishing scores increased from the lowest (201.0; 95% CI, 195.0-207.0) to medium (225.2; 95% CI, 219.4-231.0) to highest (240.4; 95% CI, 234.4-246.4) tertiles of family connection; compared with those in the lowest tertile of family connection, the flourishing scores were 1.04 (95% CI, 0.81-1.27) SD units higher among those in the highest tertile and 0.64 (95% CI, 0.42-0.86) SD units higher among those in the middle tertile. This association was also present across levels of childhood adversity. In the subgroup of respondents with 2 or more adverse childhood experiences, those in the highest tertile of family connection had adjusted flourishing scores 0.76 (95% CI, 0.14-1.38) SD units higher than those in the lowest tertile. In the subgroup with low childhood social position, those in the highest tertile of family connection had flourishing scores 1.08 (95% CI, 0.63-1.52) SD units higher than those in the lowest tertile. Conclusions and Relevance: In this cross-sectional study of young adults with type 1 diabetes, higher levels of childhood family connection were associated with greater flourishing in young adulthood across levels of childhood adversity. Beyond disease management, clinician support of family connection may help children with type 1 diabetes flourish in adulthood.

Antagonistic roles of ubiquitin ligase HEI10 and SUMO ligase RNF212 regulate meiotic recombination.

Crossover recombination facilitates the accurate segregation of homologous chromosomes during meiosis. In mammals, poorly characterized regulatory processes ensure that every pair of chromosomes obtains at least one crossover, even though most recombination sites yield non-crossovers. Designation of crossovers involves selective localization of the SUMO ligase RNF212 to a minority of recombination sites, where it stabilizes pertinent factors such as MutSγ (ref. 4). Here we show that the ubiquitin ligase HEI10 (also called CCNB1IP1) is essential for this crossover/non-crossover differentiation process. In HEI10-deficient mice, RNF212 localizes to most recombination sites, and dissociation of both RNF212 and MutSγ from chromosomes is blocked. Consequently, recombination is impeded, and crossing over fails. In wild-type mice, HEI10 accumulates at designated crossover sites, suggesting that it also has a late role in implementing crossing over. As with RNF212, dosage sensitivity for HEI10 indicates that it is a limiting factor for crossing over. We suggest that SUMO and ubiquitin have antagonistic roles during meiotic recombination that are balanced to effect differential stabilization of recombination factors at crossover and non-crossover sites.