challenges and opportunities in the management of type 1 diabetes in youth

Challenges and Opportunitiesin the Management of

Type 1 Diabetes in Youth

Lori Laffel, MD, MPHChief, Pediatric, Adolescent and Young Adult Section

Investigator, Genetics and Epidemiology SectionJoslin 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

Num

ber o

f chi

ldre

n (%

tota

l)

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 pAll 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

HbA

1c %

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

diagnosis

3 wee

ks

3 months

6 months

12 m

onths

18 m

onths

24 m

onths

c-pe

ptid

e (n

mol

/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 #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

050

100150200250300350

No Diabetes Type 1 Diabetes

Tanner I Tanner II–IV Adult

Glu

cose

Infu

sion

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

Qua

lity

of L

ife S

core

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, MPHChief, Pediatric, Adolescent and Young Adult

SectionInvestigator, Genetics and Epidemiology SectionJoslin 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

8.02468

10

Rat

e /1

00 p

atie

nt y

ears

Calendar year

10.5

9.5

9.0

121416182022

1994 1996 1998 2000 2002

Mea

n H

bA1c

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 (1

00 p

t*ye

ars)

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/comaWith help

Injections

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 <.0001School 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



AdherenceBGM

Insulin Delivery

Gender

Family

Peers/school


Affectivedisorders


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 ≥ 10SMBG # 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 12.1Age at Dx (yr) 7.8 7.6 8.7 6.6 7.9 7.3Duration (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


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 / weekMissed boluses per week

10

6

6.5

7

7.5

8

8.5

9

9.5

0 2 4 6 8

HbA

1c (%

)

*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/dL

)

*

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 ± 2.0Diabetes duration (yr) 7.6 ± 3.8 8.3 ± 3.7Pump therapy duration (yr) 3.1 ± 1.8 3.9 ± 1.9HbA1c (%) 8.0 ± 1.0 8.8 ± 1.2Mean doses / day for 4 wks (n) 5.3 ± 1.7 3.8 ± 1.7SMBG per day (n) 3.6 ± 1.8 2.4 ± 1.8Insulin dose (U/kg) 0.83 ± 0.18 0.82 ± 0.17Basal 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

1020304050

Insu

lin le

vels

(U

/mL)

Time (min)90 150 180 300

60708090

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

(mg/

kg/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 #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 careB: Tell the parents they should absolutely NOT have involvement in her care – she is almost an adultC: Try to find out more about why this is happening



Adherence

Gender

Family

Peers/school


Affectivedisorders


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

Perc

ent o

f sub

ject

s

Change in HbA1C-0.9

-0.7

-0.5

-0.3

-0.1

0.1

Cha

nge

in H

bA1c

Glucose Monitoring: SMBG & CGM

SMBG CGM


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!

challenges and opportunities in the management of type 1 diabetes in youth

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