Diabetic ketoacidosis: a canary in the mine for mental health disorders?

BACKGROUND: Recurrent diabetic ketoacidosis (DKA) has been linked to mental health disorders, but less is known about single DKA episodes. Most studies are retrospective, lacking control groups. AIMS: To prospectively examine psychosocial factors in patients presenting with recurrent or single episode DKA and compare with people who have not had DKA. METHODS: Case-controlled study (consecutive adult DKA admissions April 2015 to December 2016) at Western Health, Melbourne. Data were prospectively collected regarding diagnosed mental health disorders, likely depression (Patient Health Questionnaire (PHQ-9)), diabetes distress (Problem Areas in Diabetes (PAID) questionnaire) and presence of adverse social factors. A control group without a history of DKA was also recruited. RESULTS: Of 123 patients admitted with DKA (164 consecutive episodes), 70 consented to participate and 73 age-matched Type 1 diabetes controls were recruited. Eleven (61%) of 18 with recurrent DKA had a diagnosed mental health disorder versus 8 (19%) of 42 in the single episode group (P = 0.016). The prevalence of likely depression using PHQ-9 was: recurrent 50%; single 40%; and controls 22% (recurrent vs controls, P = 0.036; single vs controls, P = 0.053). Severe diabetes distress (PAID) was present in 47% of recurrent and 34% of single episode DKA (P = 0.387). As a group, DKA patients had significantly more unemployment, illicit drug use and tobacco smoking, a lower level of formal education and less regular medical contact compared with controls. CONCLUSIONS: Mental health disorders and adverse socioeconomic factors appear to be common in patients with DKA. The diagnosis of DKA presents an excellent opportunity to screen for depression and offer appropriate intervention.

Nurse, midwife and patient perspectives and experiences of diabetes management in an acute inpatient setting: a mixed-methods study.

BACKGROUND: In an acute hospital setting, diabetes can require intensive management with medication modification, monitoring and education. Yet little is known about the experiences and perspectives of nursing/midwifery staff and patients. The aim of this study was to investigate diabetes management and care for patients with diabetes in an acute care setting from the perspectives of nursing/midwifery staff and patients. METHODS: A convergent mixed-methods study design. Patients with diabetes (Type 1, Type 2 or gestational diabetes) recruited from a public health service in Melbourne, Australia completed a survey and nurses and midwives employed at the health service participated in focus groups. Descriptive statistics were used to summarise the survey data. Thematic analysis was used for the free-text survey comments and focus group data. RESULTS: Surveys were completed by 151 patients. Although more than half of the patients were satisfied with the diabetes care they had received (n = 96, 67.6%), about a third felt the hospital nursing/midwifery staff had ignored their own knowledge of their diabetes care and management (n = 43, 30.8%). Few reported having discussed their diabetes management with the nursing/midwifery staff whilst in hospital (n = 47, 32.6%) or thought the nurses and midwives had a good understanding of different types of insulin (n = 43, 30.1%) and their administration (n = 47, 33.3%). Patients also reported food related barriers to their diabetes management including difficulties accessing appropriate snacks and drinks (n = 46, 30.5%), restricted food choices and timing of meals (n = 41, 27.2%). Fourteen nurses and midwives participated in two focus groups. Two main themes were identified across both groups: 1. challenges caring for patients with diabetes; and 2. lack of confidence and knowledge about diabetes management. CONCLUSIONS: Patients and nursing/midwifery staff reported challenges managing patients' diabetes in the hospital setting, ensuring patients' optimal self-management, and provision of suitable food and timing of meals. It is essential to involve patients in their diabetes care and provide regular and up-to-date training and resources for nursing/midwifery staff to ensure safe and high-quality inpatient diabetes care and improve patient and staff satisfaction.

Use of a web-based educational intervention to improve knowledge of healthy diet and lifestyle in women with Gestational Diabetes Mellitus compared to standard clinic-based education.

BACKGROUND: This study introduced a web-based educational intervention for Australian women with gestational diabetes mellitus (GDM). The aim was to improve knowledge on healthy diet and lifestyle in GDM. Evaluation of the intervention explored women's knowledge and understanding of GDM, healthy diet, healthy food, and healthy lifestyle, after using the web-based program compared to women receiving standard clinic-based GDM education. METHODS: A total of 116 women, aged 18-45 years old, newly diagnosed with GDM, participated (Intervention (n) = 56 and control (n) = 60). Women were randomly allocated to the intervention or control groups and both groups attended a standard GDM education class. Group 1(Intervention) additionally used an online touch screen/computer program. All women completed a questionnaire following the computer program and/or the education class. All questions evaluating levels of knowledge had more than one correct answer and scores were graded from 0 to 1, with each correct component receiving a score, eg. 0.25 per each correct answer in a 4 answer question. Chi-square test was performed to compare the two groups regarding knowledge of GDM. RESULTS: Findings indicated that the majority of women in the intervention group reported correct answers for "types of carbohydrate foods" for pregnant women with GDM, compared to the control group (62.5 % vs 58.3 %, respectively). Most women in both groups had an excellent understanding of "fruits and vegetables" (98.2 % vs 98.3 %), and the majority of women in the intervention group understood that they should exercise daily for 30 min, compared to the control group (92.9 % vs 91.7 %). Both groups had a good understanding across all categories, however, the majority of women in the intervention group scored all correct answers (score = 1) in term of foetal effects (17.9 % vs 13.3 %, respectively), maternal predictors (5.4 % vs 5 %), care requirements (39.3 % vs 23.3 %), GDM perceptions (48.2 % vs 46.7 %) and GDM treatment (67.9 % vs 61.7 %), compared to women in the control group. CONCLUSION: The study suggested that both approaches, standard education and standard education plus web-based program, resulted in excellent knowledge scores, but not statistically significant difference between groups. Multiple and immediate access to the web-based education program at home may prove useful as a source of reference for women with GDM. Future study comparing results pre and post intervention is needed. TRIAL REGISTRATION: ACTRN12615000697583 ; Date registered: 03/07/2015; Retrospectively registered.

Development and initial testing of a GDM information website for multi-ethnic women with GDM.

BACKGROUND: Gestational diabetes mellitus (GDM) affects approximately 5-15 % of pregnant women in Australia. Highest rates are seen among women who are obese, from specific ethnic backgrounds and low socio-economic circumstance. These features also impact on uptake of self-management recommendations. GDM that is not well managed can give rise to serious pregnancy complications. The aim of this project was to develop and test an intervention to improve knowledge of GDM and GDM self-management principles. METHODS: A web-based intervention, consisting of resources aimed at a low level of literacy, was developed and tested among multi-ethnic women at a metropolitan hospital in Melbourne Australia. A basic one-group pre-test/post-test design was used to explore the impact of the intervention on knowledge, in 3 domains: (1) Knowledge of GDM; (2) food values, and;(3) GDM self-management principles. Questionnaire data was analysed using Statistical Package for the Social Sciences (SPSS), version 21.0. Fisher's exact test was used to test for an improvement in each knowledge scale. RESULTS: Twenty-one women with GDM, from multi-ethnic backgrounds, participated in the testing of the intervention. Results indicated that the intervention was effective at improving knowledge scores and this effect was greatest in the first domain, knowledge of GDM. Although some improvement of knowledge scores occurred in the other two domains, food values and self-management principles, these improvements were less than expected. This finding may relate to a number of misunderstandings in the interpretation of the web resource and survey questions. These issues will need to be resolved prior to proceeding to a clinical trial. CONCLUSION: Initial results from this study look promising and suggest that with some improvements, the intervention could prove a useful adjunct support for women with GDM from multi-ethnic and low socio-economic backgrounds. Conducting a randomised controlled trial is feasible in the future and will provide a useful means of examining efficacy of the intervention.

The high burden of inpatient diabetes mellitus: the Melbourne Public Hospitals Diabetes Inpatient Audit.

OBJECTIVE: To determine the prevalence of diabetes in inpatients in Melbourne hospitals. DESIGN: Point prevalence survey of all inpatients in each hospital on a single day between 30 November 2010 and 22 November 2012. SETTING: 11 hospitals in metropolitan Melbourne including community, secondary and tertiary hospitals and one aged care and rehabilitation centre. PARTICIPANTS: 2308 adult inpatients in all wards apart from intensive care, emergency, obstetrics and psychiatry. MAIN OUTCOME MEASURES: Point prevalence of self-reported diabetes, details of current medication, self-reported frequency of complications. RESULTS: Diabetes status was obtained in 2273 of 2308 inpatients (98.5%). Of these, 562 (24.7%) had diabetes (95% CI, 22.9%-26.5%). Diabetes prevalence ranged from 15.7% to 35.1% in different hospitals (P < 0.001). Patients with diabetes were older, heavier and more likely to be taking lipid-lowering, antihypertensive and blood-thinning medications. Of 388 patients with complete medication information, 270 (69.6%) were taking oral hypoglycaemic agents alone or in combination with insulin, 158 (40.7%) were treated with insulin (67 [17.3%] with insulin alone) and 51 (13.1%) were not taking medication for diabetes. The frequency of diabetes complications was very high: 207/290 (71.4%) for any microvascular complication, 275/527 (52.2%) for any macrovascular complication and 227/276 (82.2%) for any complication. CONCLUSION: The high burden of diabetes in Melbourne hospital inpatients has major implications for patient health and health care expenditure. Optimising care of these high-risk patients has the potential to decrease inpatient morbidity and length of stay as well as preventing or delaying future complications. A formal Australian national audit of inpatient diabetes would determine its true prevalence and consequences, allowing rational planning to deal with shortcomings in its management.

Simplified gestational diabetes screening with a triaging fasting plasma glucose reduces the burden of oral glucose tolerance tests during pregnancy - A large tertiary comparative cohort study.

AIMS: The study aimed to evaluate the impact of a simplified screeningapproach for gestational diabetes (GDM) compared to conventional screening on OGTT rates, GDM prevalence, and perinatal outcomes. METHOD: A retrospective comparative cohort study included singleton births from 20 weeks' gestation. Pregnancies without diagnostic glucose results from 13 weeks' gestation or incomplete screenings were excluded. Simplified screening consisted of a triaging fasting plasma glucose (FPG), where only those with FPG levels between 4.7 and 5.0 mmol/L proceeded to the 2hr 75 g oral glucose tolerance test (OGTT).The study period was divided into conventional screening (1st January 2019-30th June 2020) and simplified screening (1st January 2021-31st December 2021). RESULTS: Out of 15,138 pregnancies, 12,035 met the inclusion criteria: 7385 underwent conventional and 4650 underwent simplified screening. In the simplified group, 82.9 % avoided an OGTT. The simplified screening group also had a lower GDM prevalence compared to the conventional group ((18.7 % vs. 21.7 %, p < 0.001). Perinatal outcomes, including the rate of large-for-gestational-age infants, were similar between the groups. CONCLUSION: The simplified GDM screening strategy for significantly reduced OGTTs by over 80% without impacting perinatal outcomes. It suggests that prospective studies are necessary to further evaluate this approach.

Participants' and Health Care Providers' Insights Regarding a Web-Based and Mobile-Delivered Healthy Eating Program for Disadvantaged People With Type 2 Diabetes: Descriptive Qualitative Study.

BACKGROUND: Healthy eating is a key element of type 2 diabetes (T2D) self-management. Digital interventions offer new avenues to reach broad audiences to promote healthy eating behaviors. However, acceptance of these interventions by socioeconomically disadvantaged people (eg, those with lower levels of education and income or from ethnic minority groups) has not yet been fully evaluated. OBJECTIVE: This study aimed to investigate the acceptability and usability of EatSmart, a 12-week web-based and mobile-delivered healthy eating behavior change support program, from the perspective of intervention participants living with T2D and health care providers (HCPs) involved in diabetes care. METHODS: This study used a qualitative descriptive design. Overall, 60 disadvantaged adults with T2D, as determined by receipt of either a HealthCare Card or a pension or benefit as the main source of income, were recruited. Data from participants regarding their experiences with and perceptions of the program and longer-term maintenance of any behavior or attitudinal changes were collected through a web-based self-report survey with open-ended questions administered 12 weeks after baseline (54/60, 90%) and semistructured telephone interviews administered 36 weeks after baseline (16/60, 27%). Supplementary semistructured interviews with 6 HCPs involved in diabetes care (endocrinologists, accredited practicing dietitians, and diabetes nurse educators) were also conducted 36 weeks after baseline. These interviews aimed to understand HCPs' views on successful and unsuccessful elements of EatSmart as a technology-delivered intervention; any concerns or barriers regarding the use of these types of interventions; and feedback from their interactions with patients on the intervention's content, impact, or observed benefits. All data from the surveys and interviews were pooled and thematically analyzed. RESULTS: In total, 5 key themes emerged from the data: program impact on food-related behaviors and routines, satisfaction with the program, reasons for low engagement and suggestions for future programs, benefits and challenges of digital interventions, and cultural considerations. Results showed that EatSmart was acceptable to participants and contributed positively to improving food-related behaviors. Most participants (27/43, 63%) mentioned that they enjoyed their experience with EatSmart and expressed high satisfaction with its content and delivery. The educational and motivational content was considered the most useful part of the program. Benefits discussed by intervention participants included gaining health knowledge and skills, positive changes in their food purchasing and cooking, and eating greater quantities and varieties of fruits and vegetables. HCPs also described the intervention as beneficial and persuasive for the target audience and had specific suggestions for future tailoring of such programs. CONCLUSIONS: The findings suggested that this digitally delivered intervention with supportive educational modules and SMS text messages was generally appealing for both participants and HCPs. This intervention medium shows promise and could feasibly be rolled out on a broader scale to augment usual diabetes care. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/19488.

Feasibility and acceptability of an online guided self-determination program to improve diabetes self-management in young adults.

Objective: Evaluate the feasibility and acceptability of an online guided self-determination (GSD) program to improve diabetes self-management skills among young adults with type 1 diabetes (YAD). Methods: An online program comprising seven structured interactive conversations was designed. A pre- and post- interventional study used a sequential, two-phase multiple method design. Phase one comprised a training program for diabetes educators (DEs). In Phase two YAD participated in program and completed pre- and post-surveys assessing motivation to self-manage, perceived competence in diabetes and communication with DEs. Both YAD and DEs provided a program evaluation. Results: The online GSD program was acceptable, feasible and effective in improving autonomous motivation in self-management and communication with DEs. Easy access and program flexibility were highly appreciated by both participant groups and perceived to assist YAD to stay motivated. Conclusion: The program had a significant impact on the diabetes self-management of YAD and was a feasible and acceptable way to engage and communicate with DEs. The GSD platform contributes to age appropriate and person-centred diabetes self-management. It can potentially reach geographically distanced populations, or with social circumstances or other barriers impeding in-person service provision.

Women's experiences of factors that facilitate or inhibit gestational diabetes self-management.

BACKGROUND: Gestational diabetes rates have increased dramatically in the past two decades and this pattern of increase appears to relate primarily to the obesity epidemic, older maternal age and migration from world areas of high GDM risk. Women from disadvantaged and migrant backgrounds are most at risk of developing and of mismanaging this condition. The aim of the study was to explore the factors that facilitated or inhibited gestational diabetes self-management among women in a socially deprived area. METHODS: Fifteen pregnant women, with a diagnosis of gestational diabetes, were purposively recruited for this study. Qualitative semi structured interviews and 1 focus group were conducted when participants were approximately 28-38 weeks gestation. The study's theoretical framework was based on interpretative phenomenology and data was analysed using a thematic analysis approach. RESULTS: Women in this study identified a number of factors that complicated their task of GDM self-management. Barriers included: (1) time pressures; (2) physical constraints; (3) social constraints; (4) limited comprehension of requirements, and (5) insulin as an easier option. Factors facilitating GDM self-management included: thinking about the baby and psychological support from partners and families. CONCLUSION: Women from low socio economic and migrant backgrounds often struggle to comprehend GDM self-management requirements. To improve adherence to management plans, these women require educational and supportive services that are culturally appropriate and aimed at a low level of literacy.

Attitudes towards gestational diabetes among a multiethnic cohort in Australia.

AIMS: This study aimed to examine the attitudes and beliefs towards gestational diabetes of a multiethnic sample of pregnant women with gestational diabetes. BACKGROUND: Women from non-Caucasian background are disproportionately represented in gestational diabetes statistics. This is of particular importance in multicultural Australia, where increasing numbers of non-Caucasian women give birth. DESIGN: Cross-sectional survey. METHODS: The Diabetes Attitude Scale, version 3 was administered to 200 women with gestational diabetes from Vietnamese, Indian, Filipino and Caucasian backgrounds. RESULTS: A total of 143 questionnaires were returned indicating a response rate of 71·5%. There were significant between group differences in terms of educational level (p = 0·001) and English fluency (p = 0·001). Lower educational level, though not English language fluency, was associated with poorer appreciation of gestational diabetes as a serious condition and also with a lower valuing of tight glucose control. This effect was seen irrespective of ethnic group. Indian and Vietnamese women indicated a lower valuing of patient autonomy and also reported less negative psychological effects than Caucasian and Filipino women. CONCLUSIONS: Women from non-Caucasian ethnicities may be at risk of poorer self-management of gestational diabetes related to lower education, lower health literacy and a lower appreciation of gestational diabetes as a serious condition. RELEVANCE TO CLINICAL PRACTICE: Nurses and midwives provide information and advice to women with gestational diabetes. Knowledge about factors that impact on attitude towards gestational diabetes among multiethnic populations is important for developing educational programmes to address their needs.

Factors associated with breastfeeding to 3 months postpartum among women with type 1 and type 2 diabetes mellitus: An exploratory study.

PROBLEM: Breastfeeding has significant health benefits for maternal and infant health, yet women with pre-pregnancy diabetes (type 1 or type 2 diabetes mellitus) are often less likely to breastfeed compared with other childbearing women. BACKGROUND: Intention to breastfeed and making the decision to breastfeed during pregnancy are significant predictors of breastfeeding in the general population, but intention to breastfeed has not been assessed during pregnancy among women with pre-pregnancy diabetes. AIM: To investigate factors associated with breastfeeding to three months postpartum, including demographic, health and reproductive characteristics, perceived support and pre-birth intention to breastfeed, among women with pre-pregnancy diabetes. METHODS: A prospective cohort of women with pre-pregnancy diabetes was recruited at three metropolitan hospitals in Melbourne, Australia. Women completed surveys during the third trimester of pregnancy (including intention to breastfeed) and at approximately 3 months postpartum (including current breastfeeding). Factors associated with any breastfeeding at 3 months postpartum were investigated using logistic regression. FINDINGS: Pregnancy surveys were completed by 79 women; three-month postpartum data were available for 47 women. Of these, more than two-thirds (n=32, 68%) indicated that they were breastfeeding. Controlling for other relevant variables, only pre-birth intention to breastfeed was significantly associated with any breastfeeding at three months (Adjusted Odds Ratio (95% confidence intervals, p)=20.49 (20.18-20.80, 0.017)). DISCUSSION: Pre-birth intention to breastfeed was the only significant predictor of continued breastfeeding to 3 months postpartum. CONCLUSION: Pregnancy provides an important opportunity for health professionals to educate and support women with pre-pregnancy diabetes about their breastfeeding intentions.

EatSmart, a Web-Based and Mobile Healthy Eating Intervention for Disadvantaged People With Type 2 Diabetes: Protocol for a Pilot Mixed Methods Intervention Study.

BACKGROUND: People of low socioeconomic position (SEP) are disproportionately affected by type 2 diabetes (T2D), partly due to unhealthy eating patterns that contribute to inadequate disease self-management and prognosis. Digital technologies have the potential to provide a suitable medium to facilitate diabetes education, support self-management, and address some of the barriers to healthy eating, such as lack of nutritional knowledge or shopping or cooking skills, in this target group. OBJECTIVE: This study aims to test the feasibility, appeal, and potential effectiveness of EatSmart, a 12-week, evidence-based, theoretically grounded, fully automated web-based and mobile-delivered healthy eating behavior change program to help disadvantaged people living with T2D to eat healthily on a budget and improve diabetes self-management. METHODS: EatSmart is a mixed methods (quantitative and qualitative) pre-post design pilot study. Sixty socioeconomically disadvantaged people with T2D aged 18 to 75 years will be recruited. Participants will complete self-reported baseline assessments of their basic demographic and clinical data, dietary intake, dietary self-efficacy, and barriers to healthy eating. They will be provided with login access to the EatSmart web program, which includes six progressive skill-based modules covering healthy eating planning; smart food budgeting and shopping; time-saving meal strategies, healthy cooking methods, modifying recipes; and a final reinforcement and summary module. Over the 3-month intervention, participants will also receive 3 text messages weekly, encouraging them to review goals, continue to engage with different components of the EatSmart web program, and eat healthily. Participants will undertake follow-up assessments directly following the intervention 3 months post baseline and again after a 6-month postintervention follow-up period (9 months post baseline). Feasibility will be evaluated using the number of participants recruited and retained and objective indicators of engagement with the website. Program appeal and potential effects on primary and secondary outcomes will be assessed via the same surveys used at baseline, with additional questions asking about experience with and perceptions of the program. In-depth qualitative interviews will also be conducted 6 months post intervention to provide deeper insight into experiences with EatSmart and a more comprehensive description of the program's appeal. RESULTS: The EatSmart website has been developed, and all participants have viewed the modules as of May 2020. Results are expected to be submitted for publication in December 2020. CONCLUSIONS: This study will provide data to address the currently limited evidence regarding whether disadvantaged populations with T2D may benefit from digitally delivered behavior change programs that facilitate eating healthily on a budget. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12619001111167; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12619001111167. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/19488.

Psychosocial wellbeing among new mothers with diabetes: Exploratory analysis of the postnatal wellbeing in transition questionnaire.

OBJECTIVE: The Postnatal Wellbeing in Transition (PostTrans) Questionnaire assesses psychosocial wellbeing among women transitioning to motherhood while managing pre-existing diabetes. Face and content validity have been previously reported; however the PostTrans questionnaire has 51 items which imposes a substantial burden on respondents. The aim of this study was exploratory analysis of the PostTrans questionnaire to investigate whether a reduction in the number of items was statistically supported, and whether clinically meaningful subscales could be derived. METHODS: A prospective cohort of women with type 1 or type 2 diabetes was recruited from three metropolitan hospitals in Melbourne, Australia. Women completed surveys across three postnatal time points. Data were pooled for the analysis. Suitability for factor analysis was confirmed and exploratory Principal Components Analysis with oblique rotation was conducted. RESULTS: The number of responses in the pooled dataset was 117. The reduced PostTrans scale has 27 items and six factors, which together explain 68.7% of the variance. The subscales assess: feeling as if one is coping with diabetes and the infant; feeling anxious and guilty about diabetes; feeling supported by family; sensitivity to the opinions of others; prioritising self-care; and health professional support. CONCLUSION: The number of items in the PostTrans Questionnaire was reduced from 51 to 27 items. Six meaningful subscales emerged, which can help health professionals identify and address areas in which women with diabetes are experiencing psychosocial difficulties. The revised scale provides a feasible instrument to be tested for psychometric properties in a larger sample.

Pancreatic beta-cell function and immune responses to insulin after administration of intranasal insulin to humans at risk for type 1 diabetes.

OBJECTIVE: Mucosal administration of insulin retards development of autoimmune diabetes in the nonobese diabetic mouse model. We conducted a double-blind crossover study in humans at risk for type 1 diabetes to determine if intranasal insulin was safe, in particular did not accelerate beta-cell destruction, and could induce immune effects consistent with mucosal tolerance. RESEARCH DESIGN AND METHODS: A total of 38 individuals, median age 10.8 years, with antibodies to one or more pancreatic islet antigens (insulin, GAD65, or tyrosine phosphatase-like insulinoma antigen 2) were randomized to treatment with intranasal insulin (1.6 mg) or a carrier solution, daily for 10 days and then 2 days a week for 6 months, before crossover. The primary outcome was beta-cell function measured as first-phase insulin response (FPIR) to intravenous glucose at 0, 6, and 12 months and then yearly; the secondary outcome was immunity to islet antigens, measured monthly for 12 months. RESULTS: No local or systemic adverse effects were observed. Diabetes developed in 12 participants with negligible beta-cell function at entry after a median of 1.1 year. Of the remaining 26, the majority had antibodies to two or three islet antigens and FPIR greater than the first percentile at entry, as well as beta-cell function that generally remained stable over a median follow-up of 3.0 years. Intranasal insulin was associated with an increase in antibody and a decrease in T-cell responses to insulin. CONCLUSIONS: Results from this pilot study suggest that intranasal insulin does not accelerate loss of beta-cell function in individuals at risk for type 1 diabetes and induces immune changes consistent with mucosal tolerance to insulin. These findings justify a formal trial to determine if intranasal insulin is immunotherapeutic and retards progression to clinical diabetes.

Knowledge of gestational diabetes among a multi-ethnic cohort in Australia.

OBJECTIVE: to explore knowledge about gestational diabetes (GDM) among a multi-ethnic sample of women who were receiving antenatal care in Melbourne, Australia. DESIGN: cross-sectional comparative survey. SETTING: diabetes clinic located in a public hospital in Melbourne's Western suburbs. PARTICIPANTS: 143 pregnant women with GDM from Vietnamese, Indian, Filipino and Caucasian backgrounds. FINDINGS: 200 questionnaires were distributed and 143 were returned (response rate 71.5%). There were statistically significant differences between ethnic groups in terms of educational level (p=0.001) and fluency in English (p=0.001). Educational levels, measured in completed years of schooling, were lowest among Vietnamese [mean 8.5 years, standard deviation (SD) 1.0], Filipino (mean 8.9 years, SD 1.5) and Caucasian [mean 10.2 years, SD 0.9] women. Indian women had a higher mean level of education (11.6 years, SD 0.9). Fluency in English was reported by 100% of Caucasian, Indian and Filipino women, but 53.3% of Vietnamese women required interpreter services. The women's answers varied with ethnicity and educational status. Vietnamese and Filipino women displayed the least knowledge about GDM and food values. Caucasian women also scored poorly on general knowledge about GDM. Indian women scored highest across all areas of interest. KEY CONCLUSIONS: Vietnamese women had the poorest English skills and lowest educational levels, and were identified as the group at greatest risk of misunderstanding GDM. English language proficiency alone, however, was not associated with better comprehension of GDM in this study. Higher educational level was the only factor linked to increased comprehension. It is, therefore, important that new educational strategies are developed to address lower health literacy as well as cultural factors when caring for multi-ethnic populations with GDM. This approach may also serve to address lower levels of comprehension among Caucasian populations.

Development of autoantibodies to islet antigens during childhood: implications for preclinical type 1 diabetes screening.

OBJECTIVE: Serum islet antibodies signify increased risk for type 1 diabetes (T1D). Knowledge of the relationship between age and seroconversion would guide screening for at-risk individuals. We aimed to determine the effectiveness of islet antibody screening in early childhood, in particular the proportion of negative children who subsequently seroconverted. METHODS: We identified 554 children with a first-degree relative with T1D who had tested negative for islet cell antibodies (ICA) and insulin autoantibodies (IAA) when first screened at a mean age of 7.2 yr. Of 423 who were eligible, 350 consented to re-testing for ICA and IAA and antibodies to glutamic acid decarboxylase (GADAb) and tyrosine phosphatase-like insulinoma antigen IA-2 (IA2Ab) at a mean age of 11.1 yr. GADAb and IA2Ab were measured in 239 of the initial stored samples. RESULTS: Of the 350 children who tested negative at first screening, 12 (3.4%) subsequently seroconverted, becoming positive for ICA (n = 4), IAA (n = 7), GADAb (n = 6) or IA2Ab (n = 2). Of 239 initially negative for ICA and IAA, 8/239 (3.3%) now tested positive for GADAb (n = 7) or IA2Ab (n = 1). Four of these children were positive for GADAb in both tests; the one child initially positive for IA2Ab only was positive for all four antibodies 4.6 yr later and developed diabetes. CONCLUSION: Screening for ICA and IAA failed to identify 2-3% of genetically at-risk children who subsequently developed islet antibodies. Testing for GADAb and IA2Ab would not have avoided this. Maximizing the sensitivity of detecting risk for T1D requires repeat screening for islet antibodies throughout childhood.