Subject(s)
Diabetes Mellitus, Type 1 , Humans , Diabetes Mellitus, Type 1/therapy , Young Adult , Adult , Transition to Adult CareABSTRACT
OBJECTIVES: There are many educational resources for adolescents and young adults living with type 1 diabetes; however, it is unknown whether they address the breadth of topics related to transition to adult care. Our aim in this study was to collect educational resources relevant to Canadian youth and assess their quality and comprehensiveness in addressing the knowledge necessary for youth to prepare for interdependent management of their diabetes. METHODS: We conducted an environmental scan, a systematic assessment and analysis, of online education resources in English and French relevant to Canadian youth living with type 1 diabetes. Resources were screened using an open education resource evaluation grid and relevant resources were mapped to the Readiness for Emerging Adults with Diabetes Diagnosed in Youth, a validated diabetes transition readiness assessment tool. RESULTS: From 44 different sources, 1,245 resources were identified and, of these, 760 were retained for analysis. The majority were webpages (50.1%) and downloadable PDFs (42.4%), and 12.1% were interactive. Most resources covered Diabetes Knowledge (46.0%), Health Behaviour (23.8%), Insulin and Insulin Pump Management (11.8% and 8.6%, respectively), and Health-care System Navigation (9.7%). Topic areas with the fewest resources were disability accommodations (n=5), sexual health/function (n=4), and locating trustworthy diabetes resources (n=3). CONCLUSIONS: There are many resources available for those living with type 1 diabetes preparing to transition to adult care, with the majority pertaining to diabetes knowledge and the least for navigation of the health system. Few resources were available on the topics of substance use, sexual health, and reproductive health. An interactive presentation of these resources, as well as a central repository to house these resources, would improve access for youth and diabetes care providers during transition preparation.
Subject(s)
Diabetes Mellitus, Type 1 , Patient Education as Topic , Transition to Adult Care , Humans , Diabetes Mellitus, Type 1/therapy , Canada , Adolescent , Adult , Patient Education as Topic/methods , Young Adult , Male , Female , Internet , Health Knowledge, Attitudes, PracticeABSTRACT
Background: The transition to adulthood is a challenging period for individuals with type 1 diabetes, especially those attending post-secondary education (PSE) at a university or college. In addition to balancing academic responsibilities and adapting to a novel environment, young adults (YAs) with type 1 diabetes must more independently manage the daily demands of diabetes care. Objective: The aim of this study was to collect qualitative data from multiple stakeholders addressing the transition of students with type 1 diabetes into a PSE setting. Methods: A total of 15 participants were interviewed, including three health care provider diabetes educators, four parents of YAs with type 1 diabetes, and eight YAs with type 1 diabetes. Reflexive thematic analysis of the qualitative interviews revealed four major themes and 11 subthemes. Results: The four major themes revealed included 1) inappropriateness of services available to support students with type 1 diabetes in PSE settings, 2) individuals with type 1 diabetes having to compensate for inadequate systems, 3) variability of social support effectiveness, and 4) the need for a more holistic approach to improve diabetes education and social support systemically. Conclusion: This study identified some key systemic barriers experienced by PSE students with type 1 diabetes. Future research needs to extend the sample populations to understand a wider range of PSE student experiences. The findings from this study provide initial recommendations to develop new PSE readiness interventions for YAs with type 1 diabetes.
Subject(s)
Diabetes Mellitus , Health Behavior , Humans , Diabetes Mellitus/therapy , Behavior Therapy , Health PromotionABSTRACT
BACKGROUND: Despite the widespread clinical perception that hypoglycemia may drive weight gain in youth with type 1 diabetes (T1D), there is an absence of published evidence supporting this hypothesis. METHODS: We estimated the body fat percentage (eBFP) of 211 youth (HbA1c 8.0-13.0%, age 13-16) at baseline, 6, and 18 months of the Flexible Lifestyles Empowering Change trial using validated equations. Group-based trajectory modeling assigned adolescents to sex-specific eBFP groups. Using baseline 7-day blinded continuous glucose monitoring data, "more" vs. "less" percent time spent in hypoglycemia was defined by cut-points using sample median split and clinical guidelines. Adjusted logistic regression estimated the odds of membership in an increasing eBFP group comparing youth with more vs. less baseline hypoglycemia. RESULTS: More time spent in clinical hypoglycemia (defined by median split) was associated with 0.29 the odds of increasing eBFP in females (95% CI: 0.12, 0.69; p = 0.005), and 0.33 the odds of stable/increasing eBFP in males (95% CI: 0.14, 0.78; p = 0.01). CONCLUSIONS: Hypoglycemia may not be a major driver of weight gain in US youth with T1D and HbA1c ≥8.0. Further studies in different sub-groups are needed to clarify for whom hypoglycemia may drive weight gain and focus future etiological studies and interventions. IMPACT: We contribute epidemiological evidence that hypoglycemia may not be a major driver of weight gain in US youth with type 1 diabetes and HbA1c ≥8.0% and highlight the need for studies to prospectively test this hypothesis rooted in clinical perception. Future research should examine the relationship between hypoglycemia and adiposity together with psychosocial, behavioral, and other clinical factors among sub-groups of youth with type 1 diabetes (i.e., who meet glycemic targets or experience a frequency/severity of hypoglycemia above a threshold) to further clarify for whom hypoglycemia may drive weight gain and progress etiological understanding of and interventions for healthy weight maintenance.
Subject(s)
Diabetes Mellitus, Type 1 , Hypoglycemia , Adolescent , Female , Humans , Male , Adiposity , Blood Glucose , Blood Glucose Self-Monitoring , Diabetes Mellitus, Type 1/complications , Glycated Hemoglobin , Hypoglycemia/complications , Obesity/complications , Weight GainABSTRACT
Type 1 diabetes (T1D) is a lifelong and chronic condition that can cause severely compromised health. The T1D treatment regimen is complex, and is a particular challenge for adolescents, who frequently experience a number of treatment adherence barriers (e.g., forgetfulness, planning and organizational challenges, stress). Diabetes Journey is a gamified mHealth program designed to improve T1D self-management through a specific focus on decreasing adherence barriers and improving executive functioning skills for adolescents. Grounded in situativity theory and guided by a sociotechnical-pedagogical usability framework, Diabetes Journey was designed, developed, and evaluated using a learning experience design approach. This approach applied design thinking methods within a Successive Approximation Model design process. Iterative design and formative evaluation were conducted across three design phases, and improvements were implemented following each phase. Findings from the user testing phase indicate Diabetes Journey is a user-friendly mHealth program with high usability that holds promise for enhancing adolescents' T1D self-management. Implications for future designers and researchers are discussed regarding the social dimension of the sociotechnical-pedagogical usability framework. An extension to the framework is proposed to extend the social dimension to include socio-cultural and contextual considerations when designing mHealth applications. Consideration of the pedagogical and sociocultural dimensions of learning is imperative when developing psychoeducational interventions.
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OBJECTIVE: To assess the relationship between mindfulness and glycemia among adolescents with type 1 diabetes (T1D) with suboptimal glycemia, and evaluate the potential mediation by ingestive behaviors, including disordered eating, and impulsivity. RESEARCH DESIGN AND METHODS: We used linear mixed models for hemoglobin A1c (HbA1c) and linear regression for continuous glucose monitoring (CGM) to study the relationship of mindfulness [Child and Adolescent Mindfulness Measure (CAMM)] and glycemia in adolescents with T1D from the 18-month Flexible Lifestyles Empowering Change (FLEX) trial. We tested for mediation of the mindfulness-glycemia relationship by ingestive behaviors, including disordered eating (Diabetes Eating Problem Survey-Revised), restrained eating, and emotional eating (Dutch Eating Behavior Questionnaire); and impulsivity (total, attentional, and motor, Barrett Impulsiveness Scale). RESULTS: At baseline, participants (n = 152) had a mean age of 14.9 ± 1.1 years and HbA1c of 9.4 ± 1.2% [79 ± 13 mmol/mol]. The majority of adolescents were non-Hispanic white (83.6%), 50.7% were female, and 73.0% used insulin pumps. From adjusted mixed models, a 5-point increase in mindfulness scores was associated with a -0.19% (95%CI -0.29, -0.08, p = 0.0006) reduction in HbA1c. We did not find statistically significant associations between mindfulness and CGM metrics. Mediation of the relationship between mindfulness and HbA1c by ingestive behaviors and impulsivity was not found to be statistically significant. CONCLUSIONS: Among adolescents with T1D and suboptimal glycemia, increased mindfulness was associated with lower HbA1c levels. Future studies may consider mindfulness-based interventions as a component of treatment for improving glycemia among adolescents with T1D, though more data are needed to assess feasibility and efficacy.
Subject(s)
Blood Glucose , Diabetes Mellitus, Type 1 , Mindfulness , Adolescent , Blood Glucose/analysis , Blood Glucose Self-Monitoring , Diabetes Mellitus, Type 1/blood , Diabetes Mellitus, Type 1/psychology , Diabetes Mellitus, Type 1/therapy , Feeding and Eating Disorders/blood , Feeding and Eating Disorders/psychology , Female , Glycated Hemoglobin/analysis , Humans , Impulsive Behavior , Life Style , Male , Power, Psychological , Treatment OutcomeABSTRACT
OBJECTIVE: We sought to determine whether census tract poverty, race, and insurance status were associated with the likelihood and severity of diabetic ketoacidosis (DKA) hospitalization among youth with type 1 diabetes (T1D). METHODS: We conducted a retrospective population-based cohort study using Cincinnati Children's Hospital electronic medical record (EMR) data from January 1, 2011, to December 31, 2017, for T1D patients ≤18 years old. The primary outcome was admission for DKA. Secondary outcomes included DKA severity, defined by initial pH and bicarbonate, and length of stay. Exposures were the poverty rate for the youth's home census tract, parent-reported race, and insurance status. We used multivariable logistic regression to analyze effects on odds of admission. RESULTS: We identified 439 patients with T1D; 152 were hospitalized. The cohort was 48% female, 25% Black, and 36% publicly insured; the median age was 14 years. For every 10% increase in a youth's census tract poverty rate, the adjusted odds of admission increased by 22% (95% CI, 1.03-1.47). Public insurance status was associated with DKA admission (adjusted odds ratio [AOR], 2.71, 95% CI, 1.62-4.55) while race was not. There were no clinically meaningful differences in pH or bicarbonate by census tract poverty, race, or insurance status; however, Black patients experienced differences in care (eg, longer length of stay). CONCLUSION: Youth with T1D living in high poverty areas and on public insurance were significantly more likely to be admitted for DKA. Severity upon presentation was similar across exposures. Understanding contextual mechanisms by which disparities emerge will inform changes aimed at equitably improving care.
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OBJECTIVES: Our aim was to evaluate self-reported depressive symptoms and clinical outcomes during routine screening for adolescents and young adults with type 2 diabetes (T2D), and examine associations among depressive symptoms and demographic and clinical characteristics. METHODS: The Patient Health Questionnaire (PHQ) was administered to 197 adolescents and young adults with T2D using the PHQ-2 or PHQ-9 in routine pediatric diabetes care at 4 academic medical centres. Data from electronic health records were extracted from the screening date and 12 months earlier. RESULTS: Adolescents and young adults with T2D (mean age, 16.85 years; 57% male; 77.2% non-Caucasian) completed the PHQ as part of routine diabetes care. On the PHQ, 19.3% of adolescents and young adults endorsed elevated depressive symptoms (PHQ score ≥10) and, among a subsample with item-level data (n=53), 18.9% endorsed thoughts of self-harm. Subsequently, 50.0% of those with depressive symptoms had a documented referral for mental health treatment in the electronic health record after the positive screening outcome. Older age, shorter diabetes duration, higher glycated hemoglobin level, being non-Hispanic white, more blood glucose checks per day and being prescribed oral medications were significantly associated with more depressive symptoms. CONCLUSIONS: Screening for depressive symptoms identifies individuals in need of referral for mental health treatment. A focus on self-harm assessment, standardized methods for documentation of symptoms and mental health referrals and increased referral resources are needed.
Subject(s)
Depression/diagnosis , Diabetes Mellitus, Type 2/psychology , Mass Screening/statistics & numerical data , Adolescent , Female , Humans , Male , Patient Health Questionnaire , Risk Factors , Young AdultABSTRACT
Psychosocial guidelines recommend routine screening of depressive symptoms in adolescents and young adults (AYA) with diabetes. Best practices for screening in routine care and patient characteristics associated with depressive symptoms require further investigation. The purpose of this study was to examine psychometric properties of the Patient Health Questionnaire (PHQ-2 and PHQ-9); document rates of depressive symptoms and related clinical actions; and evaluate associations with patient characteristics. The Patient Health Questionnaire (PHQ-2 or PHQ-9) was administered at five pediatric academic medical centers with 2,138 youth with type 1 diabetes. Screening was part of routine clinical care; retrospective data from electronic health records were collected for the first screening date as well as 12 months prior. The PHQ demonstrated good psychometric properties. Evaluation of item-level PHQ-9 data identified 5.0% of AYA with at least moderate depressive symptoms who would not have been flagged for further screening using the PHQ-2 only. On the PHQ-9, 10.0% of AYA with type 1 diabetes endorsed elevated depressive symptoms and 7.0% endorsed thoughts of self-harm. Patients with moderate or greater depressive symptoms had a 43.9% documented referral rate for mental health treatment. Higher BMI, older age, public insurance, shorter diabetes duration, higher HbA1C, and a diabetic ketoacidosis (DKA) event in the past year were associated with depressive symptoms. The PHQ-9 identified AYA with elevated depressive symptoms that would not have been identified using the PHQ-2. Depressive symptoms were associated with negative diabetes indicators. To improve referral rates, standardized methods for provision and documentation of referrals are needed.
Subject(s)
Depression , Diabetes Mellitus, Type 1 , Adolescent , Aged , Child , Depression/diagnosis , Diabetes Mellitus, Type 1/complications , Diabetes Mellitus, Type 1/diagnosis , Humans , Mass Screening , Psychometrics , Retrospective Studies , Surveys and Questionnaires , Young AdultABSTRACT
Objectives Turner syndrome (TS) is a complex and chronic medical condition that requires lifelong subspecialty care. Effective transition preparation is needed for successful transfer from pediatric to adult care in order to avoid lapses in medical care, explore health issues such as fertility, and prepare caregivers as adolescents take over responsibility for their own care. The objective of this study was to evaluate accuracy of knowledge of personal medical history and screening guidelines in adolescents and young adults (AYA) with TS. Methods This was a prospective cross-sectional study of 35 AYA with TS of ages 13-22 years recruited from a tertiary care center. AYA completed questionnaires on personal medical history, knowledge of screening guidelines for TS, and the Transition Readiness Assessment Questionnaire (TRAQ). Results Eighty percent of AYA with TS were 100% accurate in reporting their personal medical history. Only one-third of AYA with TS were accurate about knowing screening guidelines for individuals with TS. Accuracy about knowing screening guidelines was significantly associated with TRAQ sum scores (r = 0.45, p < 0.05). However, there was no association between knowledge of personal medical history and TRAQ sum scores. Conclusions Transition readiness skills, TS-specific knowledge, and accurate awareness of health-care recommendations are related, yet distinct, constructs. Understanding of one's personal medical history is not an adequate surrogate for transition readiness. Validated tools for general transition, like the TRAQ, can be used but need to be complemented by TS-specific assessments and content. Providers are encouraged to identify opportunities for clinical and educational interventions well in advance of starting transfer to adult care.
Subject(s)
Patient Acceptance of Health Care , Patient Education as Topic , Transition to Adult Care/standards , Turner Syndrome/psychology , Turner Syndrome/therapy , Adolescent , Adult , Cross-Sectional Studies , Female , Follow-Up Studies , Humans , Male , Prognosis , Prospective Studies , Surveys and Questionnaires , Young AdultABSTRACT
BACKGROUND | Young adulthood is a vulnerable developmental period associated with increased risk for suboptimal health outcomes in youth with type 1 diabetes. Psychosocial factors have been associated with self-management and glycemic control in younger populations, but the extent to which these associations exist among young adults is poorly understood. This study aimed to examine the psychosocial functioning of young adults with type 1 diabetes and associated clinical outcomes. METHODS | Participants included young adults (n = 44) between the ages of 18 and 23 years in a pediatric setting who were preparing to transition to adult care. All participants completed self-report measures of psychosocial functioning at baseline as part of this longitudinal observational study. Outcome data included glycemic control, frequency of blood glucose monitoring, and self-management ratings at baseline and 1-year follow-up. RESULTS | Young adults with type 1 diabetes reported higher levels of depressive symptoms, lower self-efficacy, and more risk behaviors compared with previously published scores for adolescents. Young adults also reported greater resilience and transition readiness than their younger counterparts. Psychosocial variables were differentially related to glycemic control and frequency of blood glucose monitoring both cross-sectionally and longitudinally. CONCLUSION | This study provides key information about the psychosocial functioning of young adults with type 1 diabetes. It identifies relevant psychosocial factors that are associated with meaningful health outcomes during the transition preparation period. These findings may inform the development of clinical programs aimed at promoting transition preparation and health outcomes in young adults with type 1 diabetes.
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INTRODUCTION: Youth with type 1 diabetes (T1D) commonly do not meet HbA1c targets. Youth-directed goal setting as a strategy to improve HbA1c has not been well characterized and associations between specific goal focus areas and glycemic control remain unexplored. OBJECTIVE: To inform future trials, this analysis characterized intended focus areas of youth self-directed goals and examined associations with change in HbA1c over a 18 months. METHODS: We inductively coded counseling session data from youth in the Flexible Lifestyle Empowering Change Intervention (n = 122, 13-16 years, T1D duration >1 year, HbA1c 8-13%) to categorize intended goal focus areas and examine associations between frequency of goal focus areas selected by youth and change in HbA1c between first and last study visit. RESULTS: We identified 13 focus areas that categorized youth goal intentions. Each session where youth goal setting concurrently incorporated blood glucose monitoring (BGM), continuous glucose monitoring (CGM), and insulin dosing was associated with a 0.4% (95% CI: -0.77, -0.01; P = .03) lower HbA1c at the end of intervention participation. No association was observed between HbA1c and frequency of sessions where goal intentions focused on BG only (without addressing insulin or CGM) (ß: 0.07; 95% CI: -0.07, 0.21; P = .33) nor insulin dosing only (without addressing BGM or CGM) (ß: 0.00; 95% CI: -0.11, 0.10; P = .95). CONCLUSIONS: Findings exemplify how guiding youth goal development and combining multiple behaviors proximally related to glycemic control into goal setting may benefit HbA1c among youth with T1D. More research characterizing optimal goal setting practices in youth with T1D is needed.
Subject(s)
Diabetes Mellitus, Type 1/blood , Diabetes Mellitus, Type 1/psychology , Glycated Hemoglobin/metabolism , Goals , Life Style , Self-Management , Adolescent , Blood Glucose , Blood Glucose Self-Monitoring , Diabetes Mellitus, Type 1/therapy , Empowerment , Female , Humans , Hypoglycemic Agents/therapeutic use , Insulin/therapeutic use , MaleABSTRACT
OBJECTIVE: The 2017 Society of Pediatric Psychology (SPP) Workforce Survey provides self-reported compensation by pediatric psychologists, identifies predictors of compensation, and establishes a better understanding of compensation within the context of gender and race/ethnicity minority status. METHODS: SPP members who attended the SPP Annual Conference (SPPAC; April 2017) were invited to complete the survey at the conference through electronic tablets provided on-site by the Workforce Survey Committee. The survey was subsequently distributed online to SPP members who did not complete the survey at SPPAC. The statistical analyses used for this salary data employed flexible semi-parametric models, cross-validation, and prediction models for both the overall sample and academic rank subgroups. RESULTS: Of 27 potential demographic and employment-related predictors from the 2017 SPP Workforce Survey, significant predictors of salary emerged within this sample: academic rank, time since obtaining doctoral degree, managing internal and external funds (of at least $50,000), years in primary employment position, obtaining Fellowship status in the American Psychological Association (APA), and managing other employees (at least 10 people). Given low response rates for males and individuals who identify as belonging to racial and ethnic minority subgroups, only limited, exploratory results are reported for these subgroups. CONCLUSIONS: These findings suggest that not only is longevity in one's career important but managing funds/personnel and obtaining professional designations are also predictors of higher salaries for pediatric psychologists, in general. Specific implications of salary according to the psychologist's academic rank, gender, and racial/ethnicity group status are also explored.
Subject(s)
Ethnicity , Psychology, Child , Salaries and Fringe Benefits , Workforce , Adult , Female , Humans , Male , Minority Groups , Surveys and QuestionnairesABSTRACT
OBJECTIVE: To assess maintenance of improved weight outcomes in preschoolers with obesity 6 and 12 months following a randomized clinical trial comparing a home- and clinic-based behavioral intervention (Learning about Activity and Understanding Nutrition for Child Health [LAUNCH]) to motivational interviewing and standard care. STUDY DESIGN: Randomized controlled trial with children between the ages of 2 and 5 years above the 95th percentile for body mass index for age and sex recruited from 27 pediatrician offices across 10 recruitment cycles between March 12, 2012, and June 8, 2015, were followed 6 and 12 months post-treatment. Child and caregiver weight, height, and caloric intake, child physical activity, and home environment were assessed. The primary outcome was maintenance of greater reduction of percent over the 50th percentile body mass index (BMI%50th) by LAUNCH compared with motivational interviewing and standard care at the 6- and 12-month follow-up. RESULTS: Significantly lower child BMI%50th was maintained for LAUNCH compared with motivational interviewing at 12-month follow-up and to standard care at the 6-month follow-up; however, the effect sizes were maintained for comparison with standard care at 12-month follow-up. LAUNCH had significantly lower daily caloric intake compared with motivational interviewing and standard care at both follow-ups and maintained significantly fewer high-calorie foods in the home compared with standard care at 6 and 12 months and compared with motivational interviewing at 12 months. However, caloric intake increased by 12% from post-treatment. LAUNCH caregivers did not maintain improved BMI at follow-up. CONCLUSIONS: LAUNCH showed success in reducing weight in preschoolers. However, maintaining treatment gains post-treatment is more difficult. Treatment may need to last longer than 6 months to achieve optimal results. TRIAL REGISTRATION: Clinicaltrials.gov: NCT01546727.
Subject(s)
Behavior Therapy/methods , Health Behavior , Pediatric Obesity/prevention & control , Pediatric Obesity/therapy , Anthropometry , Body Mass Index , Body Weight , Caregivers , Child Nutrition Sciences , Child, Preschool , Exercise , Female , Follow-Up Studies , Health Promotion , Humans , Male , Motivational Interviewing , Pediatrics , Treatment OutcomeABSTRACT
Importance: The Flexible Lifestyles Empowering Change (FLEX) trial, an 18-month randomized clinical trial testing an adaptive behavioral intervention in adolescents with type 1 diabetes, showed no overall treatment effect for its primary outcome, change in hemoglobin A1c (HbA1c) percentage of total hemoglobin, but demonstrated benefit for quality of life (QoL) as a prespecified secondary outcome. Objective: To apply a novel statistical method for post hoc analysis that derives an individualized treatment rule (ITR) to identify FLEX participants who may benefit from intervention based on changes in HbA1c percentage (primary outcome), QoL, and body mass index z score (BMIz) (secondary outcomes) during 18 months. Design, Setting, and Participants: This multisite clinical trial enrolled 258 adolescents aged 13 to 16 years with type 1 diabetes for 1 or more years, who had literacy in English, HbA1c percentage of total hemoglobin from 8.0% to 13.0%, a participating caregiver, and no other serious medical conditions. From January 5, 2014, to April 4, 2016, 258 adolescents were recruited. The post hoc analysis excluded adolescents missing outcome measures at 18 months (2 participants [0.8%]) or continuous glucose monitoring data at baseline (40 participants [15.5%]). Data were analyzed from April to December 2018. Interventions: The FLEX intervention included a behavioral counseling strategy that integrated motivational interviewing and problem-solving skills training to increase adherence to diabetes self-management. The control condition entailed usual diabetes care. Main Outcomes and Measures: Subgroups of FLEX participants were derived from an ITR estimating which participants would benefit from intervention, which would benefit from control conditions, and which would be indifferent. Multiple imputation by chained equations and reinforcement learning trees were used to estimate the ITR. Subgroups based on ITR pertaining to changes during 18 months in 3 univariate outcomes (ie, HbA1c percentage, QoL, and BMIz) and a composite outcome were compared by baseline demographic, clinical, and psychosocial characteristics. Results: Data from 216 adolescents in the FLEX trial were reanalyzed (166 [76.9%] non-Hispanic white; 108 teenaged girls [50.0%]; mean [SD] age, 14.9 [1.1] years; mean [SD] diabetes duration, 6.3 [3.7] years). For the univariate outcomes, a large proportion of FLEX participants had equivalent predicted outcomes under intervention vs usual care settings, regardless of randomization, and were assigned to the muted group (HbA1c: 105 participants [48.6%]; QoL: 63 participants [29.2%]; BMIz: 136 participants [63.0%]). Regarding the BMIz univariate outcome, mean baseline BMIz of participants assigned to the muted group was lower than that of those assigned to the intervention and control groups (muted vs intervention: mean difference, 0.48; 95% CI, 0.21 to 0.75; P = .002; muted vs control: mean difference, 0.86; 95% CI, 0.61 to 1.11; P < .001); this group also had a higher proportion of individuals with underweight or normal weight using weight status cutoffs (95 [69.9%] in muted group vs 24 [54.6%] in intervention group and 11 [30.6%] in control group; χ24 = 24.67; P < .001). The approach identified subgroups estimated to benefit based on HbA1c percentage (54 participants [25.0%]), QoL (89 participants [41.2%]), and BMIz (44 participants [20.4%]). Regarding the HbA1c percentage outcome, participants expected to benefit from the intervention did not have significantly higher baseline HbA1c percentages than those expected to benefit from usual care (9.4% vs 9.2%; difference, 0.2%; 95% CI, -0.16% to 0.56%; P = .44). However, participants in the muted group had higher mean HbA1c percentages at baseline than those assigned to the intervention or control groups (muted vs intervention: 9.9% vs 9.4%; difference, 0.5%; 95% CI, 0.13% to 0.89%; P = .02; muted vs control; 9.9% vs 9.2%; difference, 0.7%; 95% CI, 0.34% to 1.08%; P = .001). No significant differences were found between subgroups estimated to benefit in terms of the composite outcome from the FLEX intervention (91 participants [42.1%]) vs usual care (125 participants [57.9%]). Conclusions and Relevance: The precision medicine approach represents a conceptually and analytically novel approach to post hoc subgroup identification. More work is needed to understand markers of positive response to the FLEX intervention. Trial Registration: ClinicalTrial.gov identifier: NCT01286350.
Subject(s)
Behavior Therapy , Diabetes Mellitus, Type 1/therapy , Patient Compliance , Self-Management/psychology , Adolescent , Blood Glucose Self-Monitoring/statistics & numerical data , Female , Glycated Hemoglobin/analysis , Humans , Male , Precision Medicine/methodsABSTRACT
As part of a quality improvement (QI) initiative, Cincinnati Children's Hospital Diabetes Center established a model of reliable, feasible, routine depression screening in a subspecialty clinic for adolescents with diabetes.1 On the occasion of the special section of the journal focusing on screening for, detection of, and treatment of depression in diverse settings, the purpose of this correspondence is to describe the evolution of an in-clinic, pragmatic approach to depression and suicidal ideation (SI) screening, and to evaluate depression screening scores and glycemic control across age groups over time.
Subject(s)
Depression/diagnosis , Diabetes Mellitus, Type 1/psychology , Suicidal Ideation , Adolescent , Depression/epidemiology , Depression/therapy , Diabetes Mellitus, Type 1/blood , Female , Glycated Hemoglobin/analysis , Humans , Male , Prevalence , Psychiatric Status Rating Scales , Risk FactorsABSTRACT
OBJECTIVE: To examine the prevalence and correlates of non-severe hypoglycemia among adolescents with type 1 diabetes and suboptimal glycemic control, an understudied topic in this group. METHODS: Seven days of blinded continuous glucose monitor data were analyzed in 233 adolescents at baseline of the Flexible Lifestyle Empowering Change trial (13-16 years, type 1 diabetes duration >1 year, and hemoglobin A1c [HbA1c] 8-13% [64-119 mmol]). Incidence of clinical hypoglycemia (54-69 mg/dL) and clinically serious hypoglycemia (<54 mg/dL) was defined as number of episodes ≥15 minutes. Logistic regression modeling was used to determine the correlates of long duration of hypoglycemia, categorized by median split among those who experienced hypoglycemia. RESULTS: The sample was 76.1% non-Hispanic white, 49.8% female, age = 14.9 ± 1.1 years, diabetes duration = 6.4 ± 3.7 years, and HbA1c = 9.6 ± 1.2% (81 ± 13 mmol/mol). Over 7 days, 79.4% of youth experienced ≥1 hypoglycemic episodes of <70 mg/dL, and 55.4% of youth experienced ≥1 hypoglycemic episodes of <54 mg/dL. Among all adolescents, the median duration of clinical hypoglycemia and clinically serious hypoglycemia was 21.9 (range 0-250.2) and 4.3 (range 0-209.7) minutes/day, respectively. Long duration of clinical hypoglycemia (range 1.8-17.4% time overall) and clinically serious hypoglycemia (range 1.2-14.6% time overall) was associated with older age and decreasing HbA1c. Long duration of clinically serious hypoglycemia also was associated with insulin pump use. CONCLUSIONS: Almost 80% of adolescents with elevated HbA1c had an episode of clinical hypoglycemia, and >50% had clinically serious hypoglycemia in a week. Increased education alongside access to emerging diabetes technologies may help to prevent hypoglycemia while improving glycemic control.