Does Insulin Delivery Technology Change Our Relationship with Foods? A Scoping Review.

Introduction: Automated insulin delivery (AID) systems reduce burden and improve glycemic management for people with type 1 diabetes (PwT1D) by automatically adjusting insulin as a response to measured glucose levels. There is a lack of evidence on AID and nutrition variables such as dietary intake, eating behaviors, and disordered eating. Objectives: This scoping review aims to provide a summary of the literature regarding AID and nutrition variables and to identify gaps that require further investigation. Methods: Two researchers conducted a blinded search of Medline (OVID) and PubMed for studies, including AID use (compared to non-AID use) and nutrition variables. Studies from January 2000 to July 2023 were included, as were PwT1D of all ages. Results: A total of 3132 articles were screened for appropriateness. After exclusions, 7 studies were included (2017-2023): 4 qualitative, 1 crossover, 1 randomized controlled, and 1 observational. Studies included adolescents (n = 1), adults (n = 3) or both (n = 2), and all ages (n = 1). In quantitative studies, AID was associated with lower eating distress (-0.43 ± 0.12, P = 0.004) and higher quality of life (3.1, 95% confidence interval [CI]: 0.8-5.4, P = 0.01), but not grams of carbohydrates at meals (1.0; 95% CI: -0.7 to 3.0; P = 0.24) and snacks (0.004; 95% CI: -0.8 to 0.8; P = 0.99) compared to non-AID use. In qualitative studies, AID increased the frequency and portions of food intake and led to less dietary control from parents. AID users reported eating foods higher in energy density. PwT1D were less worried about achieving accurate carbohydrate counting (CC) when using AID. Conclusions: AID use appears to influence eating behaviors, dietary patterns, and CC, although evidence was limited. AID may reduce food management burden due to the perception that AID can correct for CC inaccuracy. Significance: Further research needs to determine if AID allows for simplification of CC and improves eating behaviors while maintaining glycemic stability.

Evaluation of Support, a self-guided online type 1 diabetes self-management education and support web application-a mixed methods study.

Background: Type 1 diabetes requires making numerous daily decisions to maintain normoglycemia. Support is an evidence-based self-guided web application for type 1 diabetes diabetes self-management. Objective: Evaluate users' satisfaction with Support and investigate changes in self-reported frequency of-, fear of- hypoglycemia, and diabetes-related self-efficacy. Methods: Adults from a Quebec type 1 diabetes registry used Support. Data was collected through online surveys or extracted from the registry at 0, 6, and 12 months (number of episodes and fear of hypoglycemia). At 6 months, participants reported satisfaction with Support and diabetes-related self-efficacy. A sub-group of 16 users was interviewed about their experience. Transcripts were analyzed using inductive and deductive approaches. Results: In total, 207 accounts were created (35% men, 96% White, mean age and diabetes duration: 49.3 ± 13.8 and 25.2 ± 14.7 years). At 6 months, the median [Q1; Q3] satisfaction was 40/49 [35; 45] with a mean decrease in hypoglycemia frequency of 0.43 episodes over 3 days (95% CI: -0.86; 0.00, p = 0.051) and of -1.98 score for fear (95% CI: -3.76; -0.20, p = 0.030). Half of the participants reported increased diabetes-related self-efficacy. Conclusions: Participants reported a high level of satisfaction with Support. Its use has the potential to facilitate hypoglycemia management and increase diabetes-related self-efficacy. Trial registration: This study is registered on ClinicalTrials.gov NCT04233138.

Development of the Support self-guided, web application for adults living with type 1 diabetes in Canada by a multi-disciplinary team using a people-oriented approach based on the Behaviour Change Wheel.

Background: Diabetes self-management education and support (DSME/S) are central in type 1 diabetes (T1D) where individuals are responsible for 95% of care. In-person DSME/S programs have been proven clinically effective (e.g. optimizing glycemic management, improving diabetes-related behaviors) but are limited by a lack of accessibility and long-term follow-up. Self-guided digital tools such as web applications (web apps) can be an alternative for delivering DSME/S. Objective: This article describes the development of Support, a behavioral theory-based, self-guided, web application for adults living with T1D in the province of Quebec, Canada. Methods: A multi-disciplinary team developed Support. Patient partners first proposed its focus, learning topics, and expressed barriers to using digital tools for DSME/S. These barriers were analyzed based on the Behaviour Change Wheel. A group of healthcare professionals (HCPs) drafted the evidence-based learning content which was reviewed by external HCPs and by patient partners. Results: Support is a bilingual (English and French) web app accessible at any time via the Internet. It has four learning paths focusing on hypoglycemia and based on the user's method of diabetes treatment. Learning modules are divided into six categories with a maximum of three learning levels. It contains features such as a discussion forum, videos, and quizzes to ensure interactivity, provide social support, and maintain the motivation and long-term engagement of users. Conclusions: To the best of the authors' knowledge, Support is the first self-guided evidence-based web app for adults living with T1D. It is currently under study to evaluate its feasibility and clinical impacts.

Nutrition and food literacy among young Canadian adults living with type 1 diabetes.

AIM: Nutrition and food literacy encompasses knowledge, skills and confidence to prepare healthy meals. This project aimed to assess and compare the proportion of young Canadian adults (18-29 years old) living with type 1 diabetes and without diabetes (controls) who demonstrated adequate nutritional health literacy. METHODS: This cross-sectional study involved participants completing an online survey that included questions on socio-economic status, nutrition knowledge, confidence and skills in meal preparation and the Short Food Literacy Questionnaire (SFLQ). Proportion of participants with adequate SFLQ score (i.e. ≥34/52) was compared between the groups (two-sample t-test). RESULTS: Among the 236 people living with type 1 diabetes and 191 controls (81.5% women), mean age was 24 ± 3 years for people living with type 1 diabetes and 22 ± 3 years for controls (p < 0.001). More people living with type 1 diabetes reported adequate SFLQ score (people living with type 1 diabetes 88.0% vs. Controls 68.0%; p < 0.001). Similarly, majority of people living with type 1 diabetes prepared their own meals compared to the controls (74.5% vs. 47.6%; p < 0.001). Enhanced SFLQ score was associated with higher cooking skills (p = 0.02) and confidence (p < 0.01) in preparing healthy meals. CONCLUSIONS: Living with type 1 diabetes was associated with greater SFLQ scores among young Canadian adults. Having the independence, the confidence and skills in meal preparation were contributing factors.

Ketogenic Diet as a Normal Way of Eating in Adults With Type 1 and Type 2 Diabetes: A Qualitative Study.

OBJECTIVES: There are currently no recommendations on following the ketogenic diet (KD) in the context of diabetes and, therefore, health-care professionals may not be comfortable in supporting this dietary regimen. In this qualitative study, we aim to understand the perspective of patients with diabetes when following the KD, particularly with regard to reasons for starting the diet, motivators, support systems, sources of information and challenges. METHODS: Adults diagnosed with type 1 or type 2 diabetes who followed a KD for ≥3 months were recruited for inclusion in this study. Semistructured interviews were conducted, audio recorded and transcribed. Themes were analyzed using concept mapping until theme saturation was achieved. RESULTS: Participants were 54.5 (standard deviation 10.1) years old, on average, and had been following the KD for 6 to 19 (median 5) months; 43% were male and 79% had type 2 diabetes. The main motivation to start the diet was to improve blood glucose control or to reduce/stop taking diabetes medications, followed by weight loss and diabetes reversal. Participants reported benefits of the diet, such as improved glycemic control, weight loss and satiety, which appeared to strongly prevail over challenges, such as lack of support from health-care professionals and lack of information sources. Most participants considered the KD as a normalized way of eating that they would continue for the rest of their lives. CONCLUSIONS: A wide range of reported benefits, either expected or that emerged, strongly motivated individuals to follow the KD despite the lack of safety information and/or support. Further studies are needed to establish guidelines that health-care professionals can use to provide direction for individuals with diabetes who wish to follow the KD.

Understanding Self-Guided Web-Based Educational Interventions for Patients With Chronic Health Conditions: Systematic Review of Intervention Features and Adherence.

BACKGROUND: Chronic diseases contribute to 71% of deaths worldwide every year, and an estimated 15 million people between the ages of 30 and 69 years die mainly because of cardiovascular disease, cancer, chronic respiratory diseases, or diabetes. Web-based educational interventions may facilitate disease management. These are also considered to be a flexible and low-cost method to deliver tailored information to patients. Previous studies concluded that the implementation of different features and the degree of adherence to the intervention are key factors in determining the success of the intervention. However, limited research has been conducted to understand the acceptability of specific features and user adherence to self-guided web interventions. OBJECTIVE: This systematic review aims to understand how web-based intervention features are evaluated, to investigate their acceptability, and to describe how adherence to web-based self-guided interventions is defined and measured. METHODS: Studies published on self-guided web-based educational interventions for people (≥14 years old) with chronic health conditions published between January 2005 and June 2020 were reviewed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) Statement protocol. The search was performed using the PubMed, Cochrane Library, and EMBASE (Excerpta Medica dataBASE) databases; the reference lists of the selected articles were also reviewed. The comparison of the interventions and analysis of the features were based on the published content from the selected articles. RESULTS: A total of 20 studies were included. Seven principal features were identified, with goal setting, self-monitoring, and feedback being the most frequently used. The acceptability of the features was measured based on the comments collected from users, their association with clinical outcomes, or device adherence. The use of quizzes was positively reported by participants. Self-monitoring, goal setting, feedback, and discussion forums yielded mixed results. The negative acceptability was related to the choice of the discussion topic, lack of face-to-face contact, and technical issues. This review shows that the evaluation of adherence to educational interventions was inconsistent among the studies, limiting comparisons. A clear definition of adherence to an intervention is lacking. CONCLUSIONS: Although limited information was available, it appears that features related to interaction and personalization are important for improving clinical outcomes and users' experience. When designing web-based interventions, the selection of features should be based on the targeted population's needs, the balance between positive and negative impacts of having human involvement in the intervention, and the reduction of technical barriers. There is a lack of consensus on the method of evaluating adherence to an intervention. Both investigations of the acceptability features and adherence should be considered when designing and evaluating web-based interventions. A proof-of-concept or pilot study would be useful for establishing the required level of engagement needed to define adherence.

Changes in Accuracy of Continuous Glucose Monitoring Using Dexcom G4 Platinum Over the Course of Moderate Intensity Aerobic Exercise in Type 1 Diabetes.

Continuous glucose monitoring (CGM) systems help diabetes management in patients with type 1 diabetes (T1D) but could have lower accuracy during exercise. We aim to evaluate the dynamics of CGM accuracy during exercise in patients with T1D. Secondary analysis of data was carried out on 22 patients with T1D (glycated hemoglobin [HbA1c]: 7.3% ± 1.0%, diabetes duration: 23 ± 13 years), who did three exercise sessions (45 min at 60% VO2max on an ergocycle, 3 h postmeal) with paired Dexcom G4 Platinum, and capillary glucose values that were collected every 5 min. Dexcom accuracy was evaluated using sensor bias (SB) and absolute relative difference (ARD). For dynamics of SB analysis, data pairs following hypoglycemia correction were excluded. The analyzed data included 792 pairs (594 during 66 exercise sessions, 198 at rest before exercise). Median ARD was 8.44 (5.35-12.13)% at rest and increased to 16.77 (10.75-26.72)% during exercise (P < 0.001). During exercise, mean SB values evolved from T0 minutes = 5.95 ± 16.04 mg/dL (exercise start); T5 = 9.55 ± 16.40; T10 = 13.51 ± 18.02; T15 = 15.32 ± 20.36; T20 = 17.30 ± 18.92; T25 = 19.46 ± 17.48; T30 = 21.08 ± 19.64; T35 = 19.10 ± 20.36; T40 = 19.82 ± 20.18; and T45 = 18.02 ± 20.90 (exercise end). CGM overestimated capillary at a mean SB of 14.23 ± 16.76 mg/dL over the whole exercise session. CGM accuracy decreased during moderate aerobic exercise as previously described. However, the trend to overestimate capillary glucose was maintained at relatively stable values within 15 min of exercise initiation, which could help patients in their clinical decisions. Similar analyses would be needed for other types of exercise.

Impact of macronutrient content of meals on postprandial glucose control in the context of closed-loop insulin delivery: A randomized cross-over study.

The aim of this randomized four-way cross-over study was to examine the effect of added protein and/or fat in standard meals with a fixed carbohydrate content on postprandial glucose control with closed-loop insulin delivery in adults with type 1 diabetes. Participants (n = 15) consumed breakfast meals with a fixed carbohydrate content (75 ± 1 g) and added protein and/or fat (35 ± 2 g): (1) carbohydrate-only (standard), (2) high protein (HP), (3) high fat (HF) and (4) high fat + protein (HFHP). The closed-loop insulin delivery algorithm generated insulin bolus and infusion rates. The addition of fat, protein or both did not impact 5-hour post-meal sensor glucose area under the curve (AUC) (main outcome), mean sensor glucose or glycaemic peak as compared with a standard meal (P > 0.05). However, time to glycaemic peak was delayed by 40 minutes (P = 0.03) and 5-hour post-meal basal insulin requirements were 39% higher (P = 0.04) with an HFHP meal compared with a standard meal. In conclusion, in the context of closed-loop insulin delivery, protein and/or fat meal content affects the timing of postprandial glycaemic peak, insulin requirements and late glycaemic excursion, without impacting overall 5-hour AUC.

The challenges of achieving postprandial glucose control using closed-loop systems in patients with type 1 diabetes.

For patients with type 1 diabetes, closed-loop delivery systems (CLS) combining an insulin pump, a glucose sensor and a dosing algorithm allowing a dynamic hormonal infusion have been shown to improve glucose control when compared with conventional therapy. Yet, reducing glucose excursion and simplification of prandial insulin doses remain a challenge. The objective of this literature review is to examine current meal-time strategies in the context of automated delivery systems in adults and children with type 1 diabetes. Current challenges and considerations for post-meal glucose control will also be discussed. Despite promising results with meal detection, the fully automated CLS has yet failed to provide comparable glucose control to CLS with carbohydrate-matched bolus in the post-meal period. The latter strategy has been efficient in controlling post-meal glucose using different algorithms and in various settings, but at the cost of a meal carbohydrate counting burden for patients. Further improvements in meal detection algorithms or simplified meal-priming boluses may represent interesting avenues. The greatest challenges remain in regards to the pharmacokinetic and dynamic profiles of available rapid insulins as well as sensor accuracy and lag-time. New and upcoming faster acting insulins could provide important benefits. Multi-hormone CLS (eg, dual-hormone combining insulin with glucagon or pramlintide) and adjunctive therapy (eg, GLP-1 and SGLT2 inhibitors) also represent promising options. Meal glucose control with the artificial pancreas remains an important challenge for which the optimal strategy is still to be determined.

Practices, perceptions and expectations for carbohydrate counting in patients with type 1 diabetes - Results from an online survey.

AIMS: Characterize adult patients with diabetes on intensive insulin therapy in terms of: (a) practices and perceived difficulties relative to carbohydrate counting (CC) and diabetes treatment, and (b) their perceptions and expectations relative to CC. METHODS: Participants completed a 30-question web-based questionnaire. RESULTS: Participants with type 1 diabetes (T1D) and using CC as part of their treatment plan (n=180) were included in this analysis. Participants were predominantly women (64%), aged 42±13years old and had diabetes for 22±13years. A large proportion of participants reported being confident in applying CC (78%) and considered precise CC as being important for glycemic control (91%), while only 17% reported finding CC difficult. Despite the low perceived difficulty associated with CC, many specific difficulties were encountered by patients such as the perception that glycemia fluctuates even with appropriate CC and that CC complicates the management of diabetes. A larger proportion of participants with a lower level of education (