Effects of Low-Calorie Sweetener Restriction on Glycemic Variability and Cardiometabolic Health in Children with Type 1 Diabetes: Findings of a Pilot and Feasibility Study.

Low-calorie sweeteners (LCS) are commonly consumed by children with type 1 diabetes (T1D), yet their role in cardiometabolic health is unclear. This study examined the feasibility, acceptability, and preliminary effects of 12 weeks of LCS restriction among children with T1D. Children (n = 31) with T1D completed a two-week run-in (n = 28) and were randomly assigned to avoid LCS (LCS restriction, n = 15) or continue their usual LCS intake (n = 13). Feasibility was assessed using recruitment, retention, and adherence rates percentages. Acceptability was assessed through parents completing a qualitative interview (subset, n = 15) and a satisfaction survey at follow-up. Preliminary outcomes were between-group differences in change in average daily time-in-range (TIR) over 12 weeks (primary), and other measures of glycemic variability, lipids, inflammatory biomarkers, visceral adiposity, and dietary intake (secondary). Linear regression, unadjusted and adjusted for age, sex, race, and change in BMI, was used to compare mean changes in all outcomes between groups. LCS restriction was feasible and acceptable. No between-group differences in change in TIR or other measures of glycemic variability were observed. However, significant decreases in TNF-alpha (-0.23 ± 0.08 pg/mL) and improvements in cholesterol (-0.31 ± 0.18 mmol/L) and LDL (-0.60 ± 0.39 mmol/L) were observed with usual LCS intake, compared with LCS restriction. Those randomized to LCS restriction did not report increases in total or added sugar intake, and lower energy intake was reported in both groups (-190.8 ± 106.40 kcal LCS restriction, -245.3 ± 112.90 kcal usual LCS intake group). Decreases in percent energy from carbohydrates (-8.5 ± 2.61) and increases in percent energy from protein (3.2 ± 1.16) and fat (5.2 ± 2.02) were reported with usual LCS intake compared with LCS restriction. Twelve weeks of LCS restriction did not compromise glycemic variability or cardiometabolic outcomes in this small sample of youth with T1D. Further examination of LCS restriction among children with T1D is warranted.

Impacts of the COVID-19 Pandemic on Pediatric Type 1 Diabetes Management: A Qualitative Study.

PURPOSE: The purpose of this study was to understand impacts of the coronavirus (COVID-19) pandemic on pediatric type 1 diabetes management. METHODS: In-depth qualitative interviews were conducted with 15 parents of children (age 6-12 years) with type 1 diabetes. Parents responded to 8 open-ended questions about their experiences managing their children's type 1 diabetes during the COVID-19 pandemic. All interviews were transcribed, coded, and analyzed using qualitative thematic methods. RESULTS: Parents reported both positive and negative aspects of managing their children's type 1 diabetes during the COVID-19 pandemic. Facilitators of diabetes management included spending more time together at home and enhanced convenience of telehealth appointments and online supply ordering. Parents also described difficulties managing their children's type 1 diabetes during the COVID-19 pandemic, including a lack of structure in their child's daily routine, which led to increases in sedentary behavior. Furthermore, they reported psychosocial challenges of type 1 diabetes management, which were exacerbated by the pandemic. CONCLUSION: While the COVID-19 pandemic was described as having overall positive impacts on pediatric type 1 diabetes management, efforts to support parents in increasing children's physical activity and reducing screen time are needed, along with readily accessible mental health resources for both parents and their children with type 1 diabetes.

Rationale and design of DRINK-T1D: A randomized clinical trial of effects of low-calorie sweetener restriction in children with type 1 diabetes.

BACKGROUND: Low-calorie sweeteners (LCSs) provide sweetness without sugar or calories and are used to replace added sugars by many children with type 1 diabetes (T1D). However, the role of LCSs in diabetes management and cardiometabolic health is unclear. OBJECTIVE: The Diabetes Research in Kids Study (DRINK-T1D) aims to investigate effects of LCS restriction on glycemic variability, visceral adiposity, lipid profiles, and systemic inflammation among children 6-12 years old with T1D. METHODS: Children with T1D, who report habitual consumption of foods and beverages containing LCSs, are recruited from the Washington Nationals Diabetes Care Complex (DCC) at Children's National Hospital (CNH) in Washington, DC. Following a phone screening and two-week run-in period involving continuation of usual LCS intake, children are randomized to 12 weeks of LCS restriction (replacement of diet beverages with still or sparkling water and avoidance of other sources of LCSs) or continued usual LCS intake (control). The primary outcome is the difference in change in glycemic variability in the LCS restriction group versus the control group. Change in glycemic variability will be assessed as the difference in daily average time-in-range (TIR), measured using continuous glucose monitoring (CGM) during two weeks at the end of the 12-week intervention, compared with during the two-week run-in period prior to randomization. Participants also complete a variety of anthropometric, metabolic, dietary, and behavioral assessments throughout the 14-week study. CONCLUSIONS: DRINK-T1D is an innovative, randomized controlled trial, evaluating effects of LCS restriction on glycemic variability and cardiometabolic health in children with T1D. Findings of DRINK-T1D will support or challenge the common practice of recommending LCS use in this patient population and will have clinically relevant implications for pediatric T1D management. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT04385888.

Substance Use Among Adolescents and Young Adults With Type 1 Diabetes: Discussions in Routine Diabetes Care.

Pediatric health care providers are in a unique position to discuss the health implications of alcohol, tobacco, and drug use with adolescents and young adults (AYAs) with type 1 diabetes (T1D). This study evaluated the frequency of self-reported substance use and associated demographic and clinical characteristics in a sample of AYAs with T1D and patient-provider discussions of substance use in T1D care. Sixty-four AYAs completed questions about substance use from the Youth Risk Behavior Survey (YRBS). Corresponding diabetes clinic visits were audio-recorded, transcribed, and reviewed to examine substance use discussions. A total of 56.3% of AYAs reported ever engaging in substance use; 40.6% reported substance use within the past 30 days. Five AYAs had discussions about substance use during their most recent diabetes clinic visit. Substance use should be proactively addressed by pediatric health care providers and AYAs should be encouraged to raise questions related to substance use during clinic visits.

Diabetes-specific family conflict and responsibility among emerging adults with type 1 diabetes.

Emerging adulthood is a transitional period for type 1 diabetes management, and aspects of family functioning such as family conflict and responsibility for diabetes management likely change following high school graduation. This study examined changes in diabetes-specific family conflict, family responsibility for diabetes management tasks, and associations with glycemic control up to 1 year after high school. Seventy-nine emerging adults with type 1 diabetes (M age = 18.09 ± .43 years; 51% female; 71% Caucasian) and their parents (73% female) completed self-report measures on diabetes-specific family conflict and family responsibility at 3 consecutive clinic visits, beginning in the spring of their senior year of high school. Hemoglobin A1c (HbA1c) was obtained from medical records. Diabetes-specific family conflict was relatively low; scores did not significantly change from baseline to Time 3. Parent responsibility for diabetes care decreased from baseline to Time 3. Higher parent- and emerging adult-reported family conflict and higher parent responsibility for diabetes care were associated with worse glycemic control (ps < .05). Parent-reported family conflict and the interaction between parent-reported family conflict and responsibility predicted HbA1c 1 year after high school. Conversely, HbA1c did not predict diabetes-specific family conflict or responsibility 1 year after high school. Findings indicate that diabetes-specific family conflict is associated with glycemic control after high school, even when emerging adults assume greater responsibility for diabetes self-care. Diabetes-specific family conflict levels were generally low and did not change over time despite this transitional period. If diabetes-specific conflict is present, it should be an important avenue for potential intervention for emerging adults with type 1 diabetes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Type 1 Diabetes: Urinary Proteomics and Protein Network Analysis Support Perturbation of Lysosomal Function.

While insulin replacement therapy restores the health and prevents the onset of diabetic complications (DC) for many decades, some T1D patients have elevated hemoglobin A1c values suggesting poor glycemic control, a risk factor of DC. We surveyed the stool microbiome and urinary proteome of a cohort of 220 adolescents and children, half of which had lived with T1D for an average of 7 years and half of which were healthy siblings. Phylogenetic analysis of the 16S rRNA gene did not reveal significant differences in gut microbial alpha-diversity comparing the two cohorts. The urinary proteome of T1D patients revealed increased abundances of several lysosomal proteins that correlated with elevated HbA1c values. In silico protein network analysis linked such proteins to extracellular matrix components and the glycoprotein LRG1. LRG1 is a prominent inflammation and neovascularization biomarker. We hypothesize that these changes implicate aberrant glycation of macromolecules that alter lysosomal function and metabolism in renal tubular epithelial cells, cells that line part of the upper urinary tract.

Self-Management Strategies in Emerging Adults With Type 1 Diabetes.

INTRODUCTION: We examined changes in self-management behaviors after high school graduation in a cohort of emerging adults with type 1 diabetes. METHODS: Sixty-four emerging adults reported on diabetes self-management behaviors at three time points over a 1-year period. Glycemic control and blood glucose monitoring frequency data were collected from the medical chart. RESULTS: Collaboration with parents decreased, diabetes problem-solving and communication increased, and glycemic control worsened during the first year after high school (p < .05). Problem solving appeared to be protective against worsening glycemic control; higher baseline diabetes problem solving significantly predicted better glycemic control at the 1-year follow-up. DISCUSSION: Emerging adults demonstrate increased independence in diabetes problem solving and communication with health care providers in the year after high school. Problem-solving skills may help emerging adults adapt type 1 diabetes self-care in response to unpredictable schedules after high-school, and promoting these skills may prevent deteriorations in glycemic control during this risky period.

Changes in type 1 diabetes health indicators from high school to college.

OBJECTIVE: Evaluate trajectories of type 1 diabetes health indicators from high school through the first year of college. PARTICIPANTS: Seventy-four students with type 1 diabetes who maintained pediatric endocrinology care during the first year of college. METHODS: Hemoglobin A1c (HbA1c), blood glucose monitoring frequency, body mass index (BMI), and clinic attendance data were collected via retrospective medical chart review in spring 2012. Group-based trajectory models evaluated diabetes-related health indicators over time and identified distinct growth trajectory groups. RESULTS: BMI increased and clinic attendance decreased in the first year of college. Trajectories for other health indicators were heterogeneous and stable over time; 69% of students were classified as having stable good glycemic control. Racial minority youth and youth on conventional insulin regimens were disproportionally represented in higher-risk groups. CONCLUSIONS: Diabetes health indicators are stable or decline upon college entrance. Results signal the need for targeted support for college students with type 1 diabetes.

Outpatient Management of Pediatric Type 1 Diabetes.

The incidence of both type 1 and type 2 diabetes (T1DM and T2DM) continues to rise within the pediatric population. However, T1DM remains the most prevalent form diagnosed in children. It is critical that health-care professionals understand the types of diabetes diagnosed in pediatrics, especially the distinguishing features between T1DM and T2DM, to ensure proper treatment. Similar to all individuals with T1DM, lifelong administration of exogenous insulin is necessary for survival. However, children have very distinct needs and challenges compared to those in the adult diabetes population. Accordingly, treatment, goals, and age-appropriate requirements must be individually addressed. The main objectives for the treatment of pediatric T1DM include maintaining glucose levels as close to normal as possible, avoiding acute complications, and preventing long-term complications. In addition, unique to pediatrics, facilitating normal growth and development is important to comprehensive care. To achieve these goals, a careful balance of insulin therapy, medical nutrition therapy, and exercise or activity is necessary. Pharmacological treatment options consist of various insulin products aimed at mimicking prior endogenous insulin secretion while minimizing adverse effects. This review focuses on the management of pediatric T1DM in the outpatient environment, highlighting pharmacotherapy management strategies.

Quantitative Differences in the Urinary Proteome of Siblings Discordant for Type 1 Diabetes Include Lysosomal Enzymes.

Individuals with type 1 diabetes (T1D) often have higher than normal blood glucose levels, causing advanced glycation end product formation and inflammation and increasing the risk of vascular complications years or decades later. To examine the urinary proteome in juveniles with T1D for signatures indicative of inflammatory consequences of hyperglycemia, we profiled the proteome of 40 T1D patients with an average of 6.3 years after disease onset and normal or elevated HbA1C levels, in comparison with a cohort of 41 healthy siblings. Using shotgun proteomics, 1036 proteins were identified, on average, per experiment, and 50 proteins showed significant abundance differences using a Wilcoxon signed-rank test (FDR q-value ≤ 0.05). Thirteen lysosomal proteins were increased in abundance in the T1D versus control cohort. Fifteen proteins with functional roles in vascular permeability and adhesion were quantitatively changed, including CD166 antigen and angiotensin-converting enzyme 2. α-N-Acetyl-galactosaminidase and α-fucosidase 2, two differentially abundant lysosomal enzymes, were detected in western blots with often elevated quantities in the T1D versus control cohort. Increased release of proteins derived from lysosomes and vascular epithelium into urine may result from hyperglycemia-associated inflammation in the kidney vasculature.

Checking In: A Pilot of a Physician-Delivered Intervention to Increase Parent-Adolescent Communication About Blood Glucose Monitoring.

Low-cost, translatable interventions to promote adherence in adolescents with type 1 diabetes are needed. This study evaluated a brief physician-delivered intervention designed to increase parent-adolescent communication about blood glucose monitoring. Thirty adolescent-parent dyads completed baseline questionnaires and received the physician-delivered intervention. Participants completed follow-up questionnaires at 12 weeks; HbA1c and glucometer data were abstracted from medical charts. Parent-reported conflict surrounding diabetes management decreased from pre- to postintervention. Participants who reported adhering to the intervention plan (n = 15) demonstrated an increase in blood glucose monitoring frequency and trends in improved HbA1c and parental diabetes collaboration from pre- to postintervention. Participants and physicians reported overall satisfaction with the program. Results demonstrate initial feasibility as well as a trend toward improvement in diabetes-specific health indicators for parent-adolescent dyads who adhered to program components. Frequent joint review of glucometer data can be a useful strategy to improve type 1 diabetes-related health outcomes and parent-adolescent communication.

Mealtime behavior and diabetes-specific parent functioning in young children with type 1 diabetes.

OBJECTIVE: Management of meals and mealtime behavior is often challenging for parents of young children with Type 1 diabetes. Parent functioning related to diabetes care may directly affect mealtime behaviors and glycemic control. This study evaluated associations among diabetes-specific parent functioning, parent and child mealtime behaviors, and glycemic control. METHOD: Parents of young children with Type 1 diabetes (n = 134) completed self-report measures assessing diabetes-specific functioning (hypoglycemia fear, diabetes self-efficacy, diabetes-related quality of life) and child and parent mealtime behaviors. Hemoglobin A1c and percentage of blood glucose values out of range (<70 mg/dL or >200 mg/dL) over a 30-day period were abstracted from medical charts as indicators of glycemic control. Structural equation modeling was utilized to evaluate predictors and related outcomes of child and parent mealtime behavior. RESULTS: The proposed model fit the data very well. More frequent problematic child mealtime behaviors were associated with poorer glycemic control; however, more frequent problematic parent mealtime behaviors were marginally associated with better glycemic control. Poorer diabetes-specific parent functioning was associated with more frequent problematic child and parent mealtime behaviors. CONCLUSIONS: Problematic child mealtime behaviors, such as disruptive behavior, present a significant risk for poorer glycemic control. Parents may engage in ineffective mealtime management strategies in an effort to meet glycemic recommendations and avoid hyperglycemia and hypoglycemia. Future research will help to determine whether parents may benefit from specific, developmentally appropriate behavioral strategies to manage meals and snacks and promote optimal diabetes management.

Average Daily Risk Range (ADRR) in Young Children With Type 1 Diabetes.

OBJECTIVE: The objective was to examine the utility of the average daily risk range (ADRR) in young children with type 1 diabetes. METHODS: Self-monitored blood glucose (BG) data and A1c values were collected from 134 children (ages 2-6). Other measures of BG variability and diabetes care were calculated using self-monitored BG data. ADRR, A1c, and other glycemic indices were compared to assess their distinctiveness and utility as measures of BG variability and glycemic control. RESULTS: Of young children's ADRR values, 72% were in the "high-risk" range using adult guidelines. ADRR and A1c were highly correlated with indicators of hyperglycemia but only weakly correlated with measures of hypoglycemia. ADRR was moderately correlated with minimum BG value in the past 30 days but not percentage of BG values below 70 mg/dL. A1c was not correlated with either measure of hypoglycemia. CONCLUSIONS: ADRR values confirm the high degree of BG variability present in young children with type 1 diabetes, particularly as compared with adults. New ADRR risk guidelines are needed for pediatric patients. ADRR and A1c are adequate indicators of hyperglycemia in young children. However, both ADRR and A1c failed to effectively capture hypoglycemia risk in this sample, and neither ADRR nor A1c can take the place of review of raw BG data to evaluate BG variability in young children.

A learner-centered diabetes management curriculum: reducing resident errors on an inpatient diabetes pathway.

OBJECTIVE: Diabetes errors, particularly insulin administration errors, can lead to complications and death in the pediatric inpatient setting. Despite a lecture-format curriculum on diabetes management at our children's hospital, resident diabetes-related errors persisted. We hypothesized that a multifaceted, learner-centered diabetes curriculum would help reduce pathway errors. RESEARCH DESIGN AND METHODS: The 8-week curricular intervention consisted of 1) an online tutorial addressing residents' baseline diabetes management knowledge, 2) an interactive diabetes pathway discussion, 3) a learner-initiated diabetes question and answer session, and 4) a case presentation featuring embedded pathway errors for residents to recognize, resolve, and prevent. Errors in the 9 months before the intervention, as identified through an incident reporting system, were compared with those in the 10 months afterward, with errors classified as relating to insulin, communication, intravenous fluids, nutrition, and discharge delay. RESULTS: Before the curricular intervention, resident errors occurred in 28 patients (19.4% of 144 diabetes admissions) over 9 months. After the intervention, resident errors occurred in 11 patients (6.6% of 166 diabetes admissions) over 10 months, representing a statistically significant (P = 0.0007) decrease in patients with errors from before intervention to after intervention. Throughout the study, the errors were distributed into the categories as follows: insulin, 43.8%; communication, 39.6%; intravenous fluids, 14.6%; nutrition, 0%; and discharge delay, 2.1%. CONCLUSIONS: An interactive learner-centered diabetes curriculum for pediatric residents can be effective in reducing inpatient diabetes errors in a tertiary children's hospital. This educational model promoting proactive learning has implications for decreasing errors across other medical disciplines.

Characteristics of children with type 1 diabetes and persistent suboptimal glycemic control.

OBJECTIVE: This study aims to determine the relationship between the duration of persistent poor glycemic control in type 1 diabetes mellitus (T1DM) children and the likelihood of subsequent improvement. METHODS: A retrospective cohort study was conducted on T1DM patients aged 6-18 years, followed for at least six visits at Children's National Medical Center (Washington, DC) with at least one hemoglobin A1c (HbA1c) ≥ 10% after the first year since the initial visit (n=151). Medical records of patients with subsequently improved glycemic control were reviewed (n=39). RESULTS: Patients aged 12-18 years, females, and Medicaid patients were twice as likely to be in persistently poor control as patients aged 6-11 years, males, and privately insured patients, respectively. Each additional visit with HbA1c ≥ 10% and one percentage point increase in the mean HbA1c reduced the likelihood of subsequent improvement by 20% and 50%, respectively. Of the 39 patients with improved control, only 5 (13%) sustained their improvement for ≥ 2 years. Multiple contributing factors for improved control were identified, but no one factor explained improved control in > 25% of patients. CONCLUSION: This study suggests that the longer the duration of poor control, the more difficult it is to reverse the underlying factors of poor diabetes management. Strategies to improve regular clinic attendance along with reinforcement of changes which resulted in improved control are critical. Adolescents, females, and Medicaid patients in particular should be targeted for sustained intervention.

Authoritative parenting, parenting stress, and self-care in pre-adolescents with type 1 diabetes.

Parent involvement in type 1 diabetes (T1DM) care leads to improved adherence; however, the manner in which parents approach illness management interactions with children must also be considered. It was hypothesized that greater use of an authoritative parenting style and less parenting stress would be associated with greater behavioral adherence and better metabolic control. Ninety-five primary caregivers of preadolescents (ages 8-11) with T1DM completed questionnaires assessing parenting style, pediatric parenting stress, and child behavioral adherence. Caregivers primarily self-identified as using an authoritative parenting style. Greater authoritative parenting was associated with greater behavioral adherence and less difficulty with pediatric parenting stress; no differences in metabolic control were observed. Greater engagement in authoritative parenting behaviors may contribute to increased age-appropriate child behavioral adherence and less pediatric parenting stress. Interventions highlighting diabetes-specific authoritative parenting techniques may enhance health outcomes and improve overall family functioning.

Sleep Behaviors and Parent Functioning in Young Children With Type 1 Diabetes.

This study evaluates sleep characteristics among young children with type 1 diabetes and associations with parent sleep and emotional functioning and diabetes care. Study participants included twenty-four parents of young children with type 1 diabetes (ages 2-5) enrolled in a pilot study of a randomized-controlled trial. Child sleep characteristics were within normal limits. However, increased child bedtime resistance and behavioral insomnia were related to greater parent stress, anxiety, and depression and use of an intensive insulin regimen. Type 1 diabetes management may impact child and parent sleep as well as parent emotional functioning. Implications for practice are presented.