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Transcript of Challenges and Opportunities in the Management of Type 1 Diabetes in Youth Lori Laffel, MD, MPH...
Challenges and Opportunitiesin the Management of
Type 1 Diabetes in Youth
Lori Laffel, MD, MPH
Chief, Pediatric, Adolescent and Young Adult Section
Investigator, Genetics and Epidemiology Section
Joslin Diabetes Center, Harvard Medical School
Type 1 Diabetes - Part 1
JBW - January 2003
• 9 year old boy, otherwise healthy• Many classmates had flu• Onset of nausea, vomiting, lethargy• Call to local healthcare:
–Asked about hydration status, time of last urination
• Next morning, JBW found dead in bed
Outline: Part 1
• Changing epidemiology of diabetes in youth– Type 1 vs type 2– Epidemic rates of type 1 diabetes– Younger age of onset of type 1 diabetes
• Glycemic control– Adolescents and the DCCT– Factors related to glycemic control– A1c guidelines and A1c outcomes in T1D
• Cases
Outline: Part 2
• Other challenges– Hypoglycemia as a barrier to A1c goals– Family impact of T1D
• Changing glycemic outcomes– BG monitoring– Insulin pump use and bolus dosing
• Other opportunities– Continuous glucose monitoring
• Cases
Epidemiology - 1• 15,000 youth/yr in USA & 70,000 youth/yr
worldwide are diagnosed with T1D• 3,700 youth/yr in USA are diagnosed with
T2D; ??? numbers/yr worldwide with T2D• T1D occurs equally among males and
females; T2D occurs 1.6x more often in females than males
• T1D is more common in whites than non-whites; T2D occurs more often in racial/ethnic minorities
SEARCH Writing Group, JAMA 2007; 297:2716 WHO 2012ADA. Diabetes Care. 2008; 31:S1-20 CDC 2012ADA. Diabetes Care. 2010; 33:S11-61 IDF, World Diabetes Day 2012 CDC National diabetes fact sheet: 2011. Atlanta, GA: U.S. DHHSNIDDK. Available at:http://diabetes.niddk.nih.gov/dm/pubs/overview.index.htm. 2010
Epidemiology - 2
• ~75% of T1D is diagnosed in people <18 years old; majority of people with T1D are adults
• Majority of T2D is diagnosed in adults• 215,000 total youth in USA and >500,000
youth worldwide <20 years old with diabetes in 2010
• >371 million persons worldwide have diabetes; numbers will be >550 million by 2030
SEARCH Writing Group, JAMA 2007; 297:2716 WHO 2012ADA. Diabetes Care. 2008; 31:S1-20 CDC 2012ADA. Diabetes Care. 2010; 33:S11-61 IDF, World Diabetes Day 2012 CDC National diabetes fact sheet: 2011. Atlanta, GA: U.S. DHHSNIDDK. Available at:http://diabetes.niddk.nih.gov/dm/pubs/overview.index.htm. 2010
Diabetes in Youth & Adults: Epidemiological Trends
• Epidemic of Childhood Obesity– 1 out 3 children is overweight or obese– Increasing occurrence of type 2 diabetes in youth– 1 out of 3 children born in 2000 will develop diabetes
• Type 1 Diabetes in Youth– Increasing incidence / prevalence during 20th and 21st C– Shift towards younger age of onset
• Diabetes is increasing worldwide, with epidemic increases of type 2 diabetes in adults; rates of new onset type 1 diabetes in adults unclear
2435 youth with newly diagnosed diabetes in 2002–3at 10 study locations: 78% T1D and 22% T2D
Incidence of Diabetes in Youth in the United States
Writing Group for the SEARCH for Diabetes in Youth Study Group. JAMA. 2007;297:2716-2724.
Vehik K et al. Diabetes Care. 2007;30:502-509.
Increasing Incidence of T1D in 0-17 year old Youth in Colorado
IR of T1D increased 1.6-fold in Colorado
1978 to 2004: 14.8 to 23.9/100,000/year
• Numbers of youth with diabetes are expected to rise substantially by 2050
• Estimates based up stable annual IR of T1D and T2D, there will be ~25% more youth with T1D and ~50% more youth with T2D by 2050
• Estimates based upon the current annual IR increases of 2.3% in Colorado, USA (Vs 3.9% in Europe), there will be 300% more youth with T1D and 400% more youth with T2D by 2050AND, IN TURN, THERE WILL BE MORE CASES OF DKA
Nov 2, 2012
Annual death rates in USA from diabetes per 1,000,000 youths
Death rates mainly from acute complications: hypoglycemia and DKA.Overall decline in death rates by 61% from 1968-2009.
After initial decline, death rate increased from 1984-2009 in 10-19 y/o.
Discussion Point:Factors related to onset of T1D
• In your practice, how do you explain new onset type 1 diabetes to families? What factors related to type 1 diabetes onset do you discuss with families?
–Have a 3 minute discussion about this at each of your tables.
DCCTand
Adolescents
DCCT – Adult & Adolescent Cohorts
AdultsAdolescents
DCCT:N Engl J Med.1993J Peds, 1994
DCCT: Adolescents Vs Adults
• significantly higher A1c’s: intensive- 8.1 vs 7.1%conventional- 9.8 vs 9.0%
• significantly more hypoglycemia:intensive- 86 vs 57/100-pt-yrsconventional- 28 vs 17/100-pt-yrs
• had significantly more DKA than adults:intensive- 2.8 vs 1.8/100-pt-yrsconventional- 4.7 vs 1.3/100-pt-yrs
Intensive insulin therapy:• Improved A1c compared with conventional therapy• Reduced risk of diabetic eye disease by 53-70% (P<.05)• Reduced risk of diabetic kidney disease by 55% (P<.05)
Intensive insulin therapy required:• Multi-disciplinary team management• Education and support for insulin dosing, diet, exercise• Frequent blood glucose monitoring• Regular follow-up care
Risk of Hyperglycemia
• Due to intensity of exposure
Intensity = degree of hyperglycemia
X
duration of hyperglycemia
Risk of Retinopathy Progression According to A1c
JAMA 2002:287
A1c of 10% x3 yearsVs
A1c of 8% x8 years
Glycemic Goalsand
Glycemic Outcomesin Youth with T1D
Discussion Point:Treatment Targets
• In your practice, what clinical guidelines do you consider when establishing treatment targets? What factors impact glycemic control in youth?
–Have a 3 minute discussion about this at each of your tables.
“…near normalization ofblood glucose levels isseldom attainable inchildren and adolescentsafter the honeymoon…”
Adults <7%
ISPAD Guidelines 90-145 80-180 <7.5%
ADA Position Statement Care of Youth with T1DM 2005, updated Jan 2013
A lower goal isreasonable if itcan be achievedwithout excessive hypoglycemia
Distribution of A1c in2,873 youths from 18 countries
Mortensen et al: Diabetes Care 1997; Danne et al: Diabetes Care 2001; de Beaufort et al: Diabetes Care 2007.
1995Mean 8.61.7%
2005Mean 8.651.5%
1998Mean 8.71.8%
4 5 6 7 8 9 10 11 12 13 14 15 16 170
5
10
15
20
25
30
Nu
mb
er
of
child
ren
(%
to
tal)
HbA1c (%)
Male Female
A1c levels reflecting poor glycemic control (≥9.5%)in 17% of youths with T1D
Glycemic Control in Youth with T1D: The SEARCH for Diabetes in Youth Study
A1c in youth with T1D %*
n Good Intermediate Poor p
All 3947 44.4 38.8 16.8
Age at exam, years <.001
0-5 402 66.9 25.1 8.0 6-12 1748 54.1 34.7 11.3 13-18 1499 32.4 44.4 23.3
Petitti DB, et al. J Pediatr 2009;155:668–72; Hanberger L, et al. Diabetes Care 2008;31:927–9.*Good: ADA age-specific target
Mean A1c 8.2%
Swedish Childhood Diabetes Registry (n = 2180): mean A1c 8.3%, 30% A1c ≥9%
Diabetes Management is Suboptimal during Adolescence & Young Adulthood
These groups have the greatest proportion of patients not achieving glycemic goals
HbA
1C (%
)
Age (years)
Exchange Registry data
Beck et al. J Clin Endocrinol Metab Dec 2012; 97(12) 4383-4389
Wood J, et al. T1D ExchangeDiabetes Care ePub Jan 2013
N=13,226
Factors Related to Glycemic Control
• Attained age• Gender / Puberty• Age of onset of diabetes• Adherence• Family involvement• Conflict• New technologies / intensive therapy
IMPAIRED INSULIN ACTION IN PUBERTY A Contributing Factor To Poor Glycemic
Control In Adolescents With Diabetes
Amiel SA, Sherwin RS, Simonson DC, Lauritano AA, Tamborlane WV.
N Engl J Med. 1986 Jul 24;315(4):215-9.
Effect of Puberty on Insulin-Stimulated Glucose Metabolism in Subjects with and without Diabetes
0
50
100
150
200
250
300
350
Non Diabetic Type 1 Diabetes
Tanner ITanner II-IVAdult
GlucoseInfusionRate(mg/M2/min)
A1c According to Attained Age
7.4
7.6
7.8
8
8.2
8.4
8.6
8.8
9
0-10 11-15 16-20 21-30 31+ Years
A1c
%
Laffel LMB et al. Treatment of the child and adolescent with diabetes. Joslin’s Diabetes Mellitus, 2005. p. 711-36.
Mea
n A
1cM
ean
A1c
A1c Trajectories
Pre to PostAdolescence
Adolescenceto
Young Adulthood
Beck et al. JCEM 2012
According to Age at Onset
7.4
7.6
7.8
8
8.2
8.4
8.6
8.8
9
0-10 11-15 16-20 21-30 31+ Years
Hb
A1c
%
Laffel LMB et al. Treatment of the child and adolescent with diabetes. Joslin’s Diabetes Mellitus, 2005. p. 711-36.
Komulainen, Diab Care 22:1950 (1999)
Rapid Loss of Endogenous Insulin in Toddlers
0
0.1
0.2
0.3
diagnosi
s
3 wee
ks
3 m
onths
6 m
onths
12 m
onths
18 m
onths
24 m
onths
c-p
epti
de
(nm
ol/
L)
< 2 years
2.0 - 4.9 years
5 - 14.9 years
Young Boy using CSII HbA1c: 8.1%, 3/15/07
12 8/12 y/o boy with T1D of 11+ years durationDOB 7/15/94
T1D diagnosed 1/96 at age 18 months
Ann Intern Med 1998;128:517-523
Probability of maintaining C-peptide secretion (stimulated C-peptide level > or = to 0.20 pmol/mL) with intensive therapy (solid line) compared with conventional
therapy (dotted line) (P < 0.001)
DCCT
Intensive Rx
Conventional Rx
Case
Case #1: Overview
• A 14 year old boy with high A1c treated with a continuous subcutaneous insulin infusion (insulin pump)– He has had diabetes for 5 years and
been on the pump for 3 years– A1c was relatively stable at 7.5% until
the past 1 ½ years, when it started rising to 9%
Question #1
• What would you do?
A: Prescribe more insulin
B: Take him off the pump
C: Talk to him about complications
Impaired Insulin Action in Puberty: A Contributing Factor to Poor Glycemic Control in
Adolescents with Diabetes
0
50
100
150
200
250
300
350
No Diabetes Type 1 Diabetes
Tanner I Tanner II–IV Adult
Glu
cose
In
fusi
on
Rat
e
Amiel SA et al. N Engl J Med. 1986;315:215-219.
Effect of Puberty on Insulin-Stimulated Glucose Metabolism
Case #1: Issues to Consider
• Division of diabetes-related responsibility
• What is going on in other areas of patient’s life?
• Family conflict (general and diabetes-specific)
• How does he feel about his A1c?• Is this a safety issue? Does he need to
be taken off pump?
1 2 3 4 565
70
75
80
85
90
95
100
Qu
alit
y o
f L
ife
Sco
re
Diabetes-specific family conflict levelquintiles (1 = low, 5 = high)QoL: quality of life
Model R2 = 0.21, p < 0.02. Conflict only significant predictor (p < 0.01) of QoLAdjusted for age, T1D duration, A1c, parental involvement
Child report of diabetes-specific family conflict predicts QoL in T1D
Laffel LM, et al. Diabetes Care 2003;26:3067-73.
Challenges and Opportunities
in the Management of Type 1 Diabetes in Youth
Lori Laffel, MD, MPH
Chief, Pediatric, Adolescent and Young Adult Section
Investigator, Genetics and Epidemiology Section
Joslin Diabetes Center, Harvard Medical School
Type 1 Diabetes - Part 2
Outline: Part 2
• Other challenges– Hypoglycemia as a barrier to A1c goals– Family impact of T1D
• Changing glycemic outcomes– BG monitoring– Insulin pump use and bolus dosing
• Other opportunities– Continuous glucose monitoring
• Cases
Hypoglycemia Risk
Risk of hypoglycemia as A1c in the DCCT
NEJM 1993
Changing IR of hypoglycemia & HbA1c in population-based cohort
Bulsara MK, et al. Diabetes Care 2004;27:2293–8.
1992
11.0
10.0
8.5
8.02
46
8
10
Ra
te /1
00
pa
tie
nt
yea
rs
Calendar year
10.5
9.5
9.0
12
1416
18
20
22
1994 1996 1998 2000 2002
Me
an
Hb
A1
c
1992 1994 1996 1998 2000 2002
Calendar year
Severe hypoglycemia-LOC
A1c (%)
Severe hypoglycemic
events(per 100 pt-yrs)
p<0.001
Svoren BM, et al. Pediatrics 2003;112:914–22.
p<0.001
Adol. DCCT
Convent.(N = 103)
Adol. DCCT
Intensive
(N = 103)
Cohort 1 (1997)
(N = 299)
Cohort 2 (2002)
(N = 152)
Severe hypoglycemic events and A1C
27.8
85.7
55.5
29.4
17.1
12.76.2
15.211.7
0
10
20
30
40
50
60
All AllInjection
CSII B-B NPH
IR (
100
pt*
year
s)
29.6
48.441.8
37.033.4
Severe HypoglycemiaCSII vs injection p=0.009CSII vs NPH p<0.0001CSII vs B-B p=NSB-B vs NPH p=0.015
Seizure/ComaCSII vs injection p<0.0001CSII vs NPH p<0.0001CSII vs B-B p=0.02B-B vs NPH p=NS
Katz M, et al. Diabetes 2010. Diab Med 2012.
Incidence rate ofhypoglycemia by regimen
Seizure/coma
With help
Injections
Case
Case 2 – Young School Age Child
• 6-year-old with T1DM presently on insulin before meals and long-acting insulin
• At visit, physician notes BG at bedtime is almost always above 200 mg/dL (12 mmol/L)
Q: Why?
A: Fear of hypoglycemia
• After lunch, BG is over 200 mg/dL (12 mmol/L)
Q: Why?
A: Insulin given after lunch
Q: How do we help correct these events?
Question #2
• What would you do?
A: Prescribe less insulin
B: Start pump therapy with CGM
C: Provide additional education and support
Children with
T1DM (n = 583)
Children with special
healthcare needs
(n = 39,944)
Children without special
healthcare needs
(n = 4,945)
p* p†
Any family impact 75% 45% 17% <.0001 <.0001
Work restriction 35% 24% 4% .0002 <.0001
Financial impact 38% 23% 6% <.0001 <.0001
Financial probs 32% 18% 4% <.0001 <.0001
Med exp >$1K 41% 20% 8% <.0001 <.0001
Time impact 24% 9% 3% <.0001 <.0001
School absence 20% 14% 2% .06 <.0001
* p value for T1DM vs Children with Special Healthcare Needs† p value for T1DM vs Children without Special Healthcare Needs
Katz M, Laffel L, et al. J Pediatr 2012
Family impact measures in children with T1DM:With or without special healthcare needs
Children with
T1DM (n = 583)
Children with special
healthcare needs
(n = 39,944)
Children without special
healthcare needs
(n = 4,945)
p* p†
Any family impact 75% 45% 17% <.0001 <.0001
Work restriction 35% 24% 4% .0002 <.0001
Financial impact 38% 23% 6% <.0001 <.0001
Financial probs 32% 18% 4% <.0001 <.0001
Med exp >$1K 41% 20% 8% <.0001 <.0001
Time impact 24% 9% 3% <.0001 <.0001
School absence 20% 14% 2% .06 <.0001
* p value for T1DM vs Children with Special Healthcare Needs† p value for T1DM vs Children without Special Healthcare Needs
Katz M, Laffel L, et al. J Pediatr 2012
Family impact measures in children with T1DM:With or without special healthcare needs
Discussion Point: Obstacles to Achieving
Management and Metabolic Goals:
• At your tables, identify 3 obstacles that you think are responsible for making it difficult for patients and their families to achieve optimal metabolic goals.
– Have a 3 minute discussion about this at each of your tables.
Adherence and Family Behavior in Children with Type 1 DM
1) Advances in DM treatment (“intensive therapy”)a) improves metabolic control, prevents complicationsb) increases the importance of adherencec) places increased demands on youth and their families
2) family conflict (DM and general) correlate with treatment adherence
3) developmentally appropriate parental involvement leads to adherence and metabolic control
Factors influencing treatmentadherence in adolescents with T1D
Borus JS, Laffel L. Curr Opin Pediatr 2010;22:405–11.
Adherence
Gender
Family
Peers/school
TechnologiesDisorderedeating
Affectivedisorders
Diabetes-specificconflict
Age
Diabetesduration
Factors influencing treatmentadherence in adolescents with T1D
Borus JS, Laffel L. Curr Opin Pediatr 2010;22:405–11.
AdherenceBGM
Insulin Delivery
Gender
Family
Peers/school
TechnologiesDisorderedeating
Affectivedisorders
Diabetes-specificconflict
Age
Diabetesduration
Blood GlucoseMonitoring
isKey
BG Monitoring Improves HbA1c
Anderson: J Peds, 1997Levine: J Peds, 2001Laffel: J Peds, 2003
P<0.02
• A1c was 0.2% lower per each additional BG check per day across the range of BG checks.
• A1c was 0.5% lower per each additional BG check per day from 0-5 checks per day.
N=26,179
63
A1c by Frequency of BG Monitoring
10.0%
8.9%8.4%
8.1% 7.8%8.9%
8.2%
7.6% 7.4% 7.1%7.0%7.5%8.0%8.5%9.0%9.5%
10.0%10.5%11.0%
0-2 3-4 5-6 7-9 ≥ 10
SMBG # Per Day
Child ( < 18 Years)
Adult ( ≥ 18 Years)
Miller et al. Diab Care 2013 Feb 1. [Epub ahead of print]
• Family involvement is necessary for successful adherence to treatment programs – new technologies, pumps, etc.
Motivation for Pump Use
63%
43%
9% 8%2%
0%
10%
20%
30%
40%
50%
60%
70%
ImproveControl
IncreaseFlexibility
FewerInjections
Food Camp
Total
(N= 2743)
Pump
MDI: Basal
Analog/Rapid
MDI: Basal
Analog/Rapid + Other
MDI: No
Basal Analog
One-Two Injections/
No Basal Analog
Age (yr) 13.2 14.0 14.0 12.3 13.0 12.1
Age at Dx (yr) 7.8 7.6 8.7 6.6 7.9 7.3
Duration (yr) 5.0 6.0 4.9 5.3 4.7 4.4
A1C 8.5±1.5 8.0±1.1 8.5±1.6 8.9±1.6 8.6±1.6 8.6±1.7
Total 100.0% 22.0% 24.8% 10.5% 15.7% 27.0%
Mean A1c by Insulin Regimen inThe SEARCH for Diabetes in Youth
Study
Paris CA, et al. J Pediatr 2009;155:183–9.
Glargine-Based MDI Compared to CSII
<6 6-12 13-19 20-<260%
10%
20%
30%
40%
50%
60%
43%
54% 52%56%57%
46% 48%44%
PumpInjection
Age, years
Insulin Delivery Method according to Age
Beck et al. JCEM 2012
Discussion Point: Obstacles to Achieving
Management and Metabolic Goals:
• At your tables, identify 3 challenges related to insulin pump therapy.
– Have a 3 minute discussion about this at each of your tables.
Challenges of Pump Use Vs Injection Rx
79%
47% 53%
23%
0%
20%
40%
60%
80%
100%
Insulin After Eating Forgets Insulin
Pump Injections
p<0.0001 p<0.0001
Q: When kids forget one bolus of insulin every other day,
• 1:___it has no impact on glycemic control or the A1c.
• 2:___the A1c increases by 0.5%.• 3:___the A1c increases by 1.0%.• 4:___the A1c increases by 2.0%.
Consistent bolus dosing is important
Burdick J, et al. Pediatrics 2004;113:e221–4.
Missed insulin meal boluses and A1cA1c correlated with number of missed insulin meal boluses per day
(r = 0.4; n = 48)
A1c increases 1% / 4 missed boluses / week
Missed boluses per week
10
6
6.5
7
7.5
8
8.5
9
9.5
0 2 4 6 8
Hb
A1
c (%
)
*p < 0.001 for AUC glucose and glucose
Missed insulin boluses for snacks in youth with T1D
• 9 youth with T1DM, sensor-augmented pump Rx• 15 y/o, diabetes for 8 yrs, mean A1c 7.6%• Over 3 months: 101 snacks with insulin, 94 snacks without insulin
Vanderwel BW, et al. Diabetes Care 2010;33:507–8.
Comparison of glucose excursions for snacks with and without insulin bolus
Glu
cose
leve
l (m
g/d
L)
*
50
100
150
200
250
300
350
0 50 100 150 200
Time (minutes)
Snacks with insulin
Snacks without insulin
• 90 youths with T1D for 8 ± 4 yrs, 12-18 y/o (15±2 yr)• CSII for 3 years, A1c 8.3 ± 1.2%• 24 hour diet recall compared with bolus Hx from pump download
– Insulin omission was common, associated with less BGM, higher basal rates, and higher A1c
*p ≤ 0.001
Olinder AL, et al. Pediatr Diabetes 2009;10:142–8.
Missed bolus doses: devastating for metabolic control in csii-treated adolescents with T1D
Missed ≤15% (n = 56)
(62%)
Missed >15% (n = 34)(38%)
Age (yr) 14.8 ± 2.2 14.9 ± 2.0
Diabetes duration (yr) 7.6 ± 3.8 8.3 ± 3.7
Pump therapy duration (yr) 3.1 ± 1.8 3.9 ± 1.9
HbA1c (%) 8.0 ± 1.0 8.8 ± 1.2
Mean doses / day for 4 wks (n) 5.3 ± 1.7 3.8 ± 1.7
SMBG per day (n) 3.6 ± 1.8 2.4 ± 1.8
Insulin dose (U/kg) 0.83 ± 0.18 0.82 ± 0.17
Basal dose/total dose (%) 55 ± 12 65 ± 14
*
*
*
*
% Of participants reporting missing an insulin dose at least once weekly
Type 1 diabetes exchange, AADE Indianapolis 2012
Why is remeal bolusing is important?
0.2 U/kg bolus of rapid-acting insulin analog at time = 0
Peak insulinlevels at ~60 min
Swan KL, et al. Diabetes Care 2009;32:240–4.
• 21 youths with T1DM• 8–17 years old
• HbA1c 6.5–8.9%
PD and PK properties of rapid-acting insulin analog in pump therapy in youth with T1DM
0 30 60 120 210 240 2700
10
20
30
40
50
Insu
lin le
ve
ls (U
/mL
)
Time (min)90 150 180 300
60
70
80
90
100110
Pre-pubertalPubertal
Pharmacodynamics of AspartPharmacodynamics of rapid-acting insulin analog
GIR 37% greater in pre-pubertal vs pubertal patients, p < 0.01
0 30 60 120 210 240 2700
1.0
2.0
3.0
4.0
GIR
(m
g/k
g/m
in)
Time (min)
90 150 180 300
5.0
6.0
7.0
8.0
9.0
Swan KL et al. Diabetes Care 2009;32:240–4.
Time to peak insulin action at ~100 min
Pre-pubertalPubertal
Time to peak similarin pre- and pubertal pts
Diabetes Care 2006; 29:2355-60
• To examine longitudinal outcomes of pump use• To identify predictors of insulin pump success• To assess rates of and reasons for pump discontinuation
Of 161 youth, 29 (18%) discontinued pump use over 3.8 years
• 28% DKA, insulin omission• 28% diabetes burnout• 21% infusion site issues• 14% body image concerns• 10% weight gain
Glycemic Control According to Pump Use
BGM frequency 3.6 Vs 4.0 VsX/day 4.1* 4.7*
(n=29)
(n=132)
Factors Associated with Unsuccessful Pump RxComparison of youth resuming MDI
with youth continuing CSII:
• Slight female excess: 90% Vs 67% (p<0.02)
• Slight post-pubertal excess: 97% Vs 74% (p<0.03)
• Single parent families: 29% Vs 4% (p<0.01)
• Increase in hypoglycemia with CSII: 23.2 Vs 7.4 events/100 pt-yrs (p<0.01)
Wood, Laffel et al. Diabetes Care 2006
Case
Case #3: Overview
• A 17 year old girl with 2 hospitalizations for DKA in the past year– T1D since age 10– Relatively good control of diabetes until
age 15, then A1c up to 11% – She does all diabetes management on own
– does not want parents involved
Question #3
• What would you do?A: Tell the parents to get more involved in her care
B: Tell the parents they should absolutely NOT have involvement in her care – she is almost an adult
C: Try to find out more about why this is happening
Factors influencing treatmentadherence in adolescents with T1D
Borus JS, Laffel L. Curr Opin Pediatr 2010;22:405–11.
Adherence
Gender
Family
Peers/school
TechnologiesDisorderedeating
Affectivedisorders
Diabetes-specificconflict
Age
Diabetesduration
Case #3: Issues to Consider
• What is going on in other areas of her life?• Anything new in past year?• Possible eating disorder?• How does she feel about her diabetes?• Why is she omitting insulin? • How does the family interact around
diabetes?
• ~30% of females teens with T1D had DEBs or EDs• ~30% used insulin restriction or omission for weight loss• Those with DEB/EDs had higher A1c by ~2%• During 4 years of F/U, those with DEB/EDs had 3x the
risk of retinopathy and 2x the risk of microalbuminuria
Opportunities with CGM Use
Continuous data, revealing rate and direction of change
Improve diabetes management and self-efficacy Immediate feedback regarding insulin, diet,
exercise, stress Alarms and trend data can help prevent
hypo- and hyper-glycemia Retrospective data allows refinement of Rx
Reduce anxiety about hypoglycemia Reduce family conflict due to better control, or
greater awareness that BG numbers do not always reflect behavior in a predictable way
Challenges of CGM Use Increase anxiety and/or depressive symptoms
Too much information/overwhelming? CGM leads to excessive focus on numbers? Increase awareness of out-of-range values Disagreement between CGM and traditional
BGM values Burden associated with insertion, calibration, tape,
alarms Increase family conflict (e.g., parental blame if
awareness of out-of-range values increases)
With negative impact of CGM less CGM usage
Relationship Between Change in HbA1c and Frequency of CGM
Use
Age 8-14 Age 15-24 Age ≥250%
20%40%60%80%
100%
CGM Use
<4.0 days/week 4.0-<6.0 days/week ≥6.0 days/week
Pe
rce
nt
of
su
bje
cts
Change in HbA1C-0.9
-0.7
-0.5
-0.3
-0.1
0.1
Ch
an
ge
in
Hb
A1
c
Glucose Monitoring: SMBG & CGM
SMBG CGM
Beck et al. JCEM 2012
Challenges of CGM Usefor Families and Youth with
T1D• Parents seek improved approaches to care;
parents provide consent, youth “go along for the ride”
• Youth expect devices to make management easier; unrealistic expectations for “cure” with artificial pancreas
• Parents of younger children remain involved, parents of adolescents disengage with increased adolescent autonomy and need for privacy (sensors worn on body = personal invasion)
• Parents of younger children often fear low BGs more than high BGs
• Children do not look at receiver; adolescents often ignore “nuisance” alarms
Opportunities& Ongoing Challenges
• In the post-DCCT era, more pediatric patients with T1DM receive intensive diabetes management leading to improved glycemic control
• There remains a significant gap between current glycemic outcomes and glycemic targets in pediatric patients today
• Present: education, technologies, and multi-disciplinary support to reduce the gap
• Future: CGM and closing the loop
Diabetes management from childhood to adolescence to young adulthood
CHILDHOOD ADOLESCENCE YOUNG ADULTHOOD
Diabetes is NOT a do-it-yourself condition at any age!
Garvey, Markowitz, Laffel Curr Diab Reports 2012
THANK YOU!