Predictors of parental interest in continuous glucose monitoring for children with type 1 diabetes.
ABSTRACT Optimal control of type 1 diabetes (T1D) in children minimizes long-term complications, but increases hypoglycemic events. A continuous glucose monitor (CGM) can provide real-time information about glucose levels and trends. Little has been published on the characteristics of patients most willing to use CGM.
Online survey software was utilized to administer a 50-item questionnaire to parents of children with T1D. The primary outcome was whether the parent expressed a high level of interest in CGM. The proportion of parents who expressed a high level of interest was compared across demographic and clinical variables via chi(2) tests (alpha = 0.05).
Analysis was performed on 457 surveys. The mean +/- SD age of the children was 10 +/- 4.1 years. Mean reported hemoglobin A1c (HbA1c) was 7.8 +/- 1.3%. Of the respondents, 70% used continuous subcutaneous insulin infusion (CSII). Parents reported an average of eight blood glucose (BG) checks daily. Over 90% of the parents indicated a high level of interest in having their child use a CGM. Primary variables related to interest in a CGM were use of CSII (P = 0.002), checking BG more than six times daily (P = 0.005), and parental worry about high or low BG (P = 0.0012 and P = 0.02, respectively). Age of the child and HbA1c were not related to parental interest in a CGM.
Overall parental interest in CGM was high. Use of CSII, frequent BG checks, and parental worry, but not age of the child or diabetes control, were associated with parental interest in using a CGM.
- SourceAvailable from: Elissa R Weitzman[Show abstract] [Hide abstract]
ABSTRACT: IMPORTANCE: Surveillance systems for elucidating the burden of hypoglycemia are limited. OBJECTIVE: To quantify experiences of hypoglycemia and related harms, members of an international online diabetes social network with insulin-dependent diabetes mellitus were polled through a software application ("app"). Aggregate results were returned to participants through network channels. DESIGN: The study period was from March 2011 through April 2012, during which time retrospective reports about experiences with hypoglycemia and related harms were collected from participants using the app. SETTING: The study was undertaken within the TuDiabetes.org international online diabetes social network. PARTICIPANTS: Eligibility criteria included TuDiabetes membership, age 13 years or older, a self-reported diagnosis of diabetes mellitus, ability to read and write English, and Internet access. Of 2827 app users, 687 (response rate, 24.3%) opted in to the volunteer sample. MAIN OUTCOME MEASURES: Primary outcomes included the following: frequency of "going low" (having a low glucose value in the past 2 weeks) and episodes of severe hypoglycemia (in the past 12 months), and, for respondents reporting recent and/or severe hypoglycemia, lifetime experience of vehicle crashes or severe medical injury, daily debilitating worry, and withdrawal from driving, exercise, sex, and going outside of the home to avoid hypoglycemia and consequences. Secondary outcomes included measures of research engagement. RESULTS: Of 613 respondents (24.3% of app users), 49.1% reported more than 4 episodes of "going low" in the past 2 weeks and 29.2% reported 1 or more severe low in the past year; 16.6% reported both more than 4 recent low episodes and 1 or more severe event in the past year. Harms were common, including daily debilitating worry (45.8%), vehicle crash or injury (15.0%), and withdrawal from exercise, driving, leaving home, and having sex (54.0%, 37.4%, 24.8%, and 22.7%, respectively). Of all respondents, 54.2% reported multiple harms, the risks for which were highest (73.7%) among respondents with a past-year severe event (odds ratio, 2.39; 95% CI, 1.60-3.58; P < .001 controlling for frequent recent low episodes and demographic and disease factors). Engagement was high, with 96.6% of the sample permitting recontact for research and 31.7% posting personal study data on their app profile page; 40.5% of 2825 unique page views of research-related materials published on the community site involved views of returned research results. CONCLUSIONS AND RELEVANCE: Participatory surveillance of hypoglycemia in an online diabetes social network enables characterization of patient-centered harms in a community sample and bidirectional communication with affected persons, augmenting traditional surveillance.JAMA Internal Medicine 02/2013; 173(5):345-51. · 13.25 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: To examine the impact of continuous glucose monitoring on diabetes management and marital relationships of adults with Type 1 diabetes and their spouses. Nine younger (30-49 years) and 11 older (50-70 years) patients with Type 1 diabetes and 14 spouses participated in eight focus groups specific to age and role (patient or spouse). Audio-recorded data were transcribed, coded and analysed using thematic analysis and aided by NVivo software. Qualitative analysis revealed participants perceived continuous glucose monitoring as positively influencing hypoglycaemia management by decreasing spouses' anxiety, vigilance and negative experiences. Participants also described continuous glucose monitoring as promoting collaborative diabetes management and increasing spousal understanding of diabetes, especially when planning and managing pregnancy. Couples' conflicts occurred when (1) patients assumed sole responsibility for continuous glucose monitoring and/or did not respond to night-time glucose alarms and (2) spouses did not understand alarms and felt frustrated and helpless to assist patients. Our findings suggest that continuous glucose monitoring may positively impact collaborative diabetes management and marital relationships of patients with Type 1 diabetes and spouses. However, reluctance to collaborate and lack of understanding may contribute to couples' conflicts around continuous glucose monitoring. Our findings have important implications for clinical care and point to the need for interventions that include spouses in continuous glucose monitoring training to increase their understanding of continuous glucose monitoring, minimize risk for spousal conflict and enhance collaborative diabetes management. Further studies are needed to explore these issues in more detail and depth with larger and more diverse populations. This article is protected by copyright. All rights reserved.Diabetic Medicine 07/2013; · 3.24 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: Ensuring quality of life (QOL) while maintaining glycemic control within targets is an important challenge in type 1 and type 2 diabetes treatment. For children with diabetes, QOL includes enjoying meals, feeling safe in school, and perceiving positive, supportive relationships with parents, siblings, and friends. Yet many treatment-related and psychosocial barriers can interfere with a child's QOL and their ability to manage diabetes effectively. Diabetes management also imposes considerable lifestyle demands that are difficult and often frustrating for children to negotiate at a young age. Recent advances in diabetes medications and technologies have improved glycemic control in children with diabetes. Two widely used technologies are the insulin pump and continuous glucose monitoring (CGM) system. These technologies provide patients with more flexibility in their daily life and information about glucose fluctuations. Several studies report improvements in glycemic control in children with type 1 diabetes using the insulin pump or sensor-augmented pump therapy. Importantly, these technologies may impact QOL for children and families with diabetes, although they are rarely used or studied in the treatment of children with type 2 diabetes. Further, emerging closed loop and web- and phone-based technologies have great potential for supporting diabetes self-management and perhaps QOL. A deeper understanding and appreciation of the impact of diabetes technology on children's and parents' QOL is critical for both the medical and psychological care of diabetes. Thus, the purpose of this review is to discuss the impact of new diabetes technologies on QOL in children, adolescents and families with type 1 diabetes.Current Diabetes Reports 08/2012; 12(6). · 3.38 Impact Factor
Predictors of Parental Interest in Continuous Glucose
Monitoring for Children with Type 1 Diabetes
Laurissa Kashmer, M.D.,1William Clarke, M.D.,1Matthew Gurka, Ph.D.,2Swati Elchuri, M.D.,3
Maren Nyer, M.Ed.,4and Linda Gonder-Frederick, Ph.D.4
Background: Optimal control of type 1 diabetes (T1D) in children minimizes long-term complications, but
increases hypoglycemic events. A continuous glucose monitor (CGM) can provide real-time information about
glucose levels and trends. Little has been published on the characteristics of patients most willing to use CGM.
Methods: Online survey software was utilized to administer a 50-item questionnaire to parents of children with
T1D. The primary outcome was whether the parent expressed a high level of interest in CGM. The proportion of
parents who expressed a high level of interest was compared across demographic and clinical variables via w2
Results: Analysis was performed on 457 surveys. The mean?SD age of the children was 10?4.1 years. Mean
reported hemoglobin A1c (HbA1c) was 7.8?1.3%. Of the respondents, 70% used continuous subcutaneous
insulin infusion (CSII). Parents reported an average of eight blood glucose (BG) checks daily. Over 90% of the
parents indicated a high level of interest in having their child use a CGM. Primary variables related to interest in
a CGM were use of CSII (P¼0.002), checking BG more than six times daily (P¼0.005), and parental worry about
high or low BG (P¼0.0012 and P¼0.02, respectively). Age of the child and HbA1c were not related to parental
interest in a CGM.
Conclusions: Overall parental interest in CGM was high. Use of CSII, frequent BG checks, and parental worry,
but not age of the child or diabetes control, were associated with parental interest in using a CGM.
of hypoglycemia.1,2Attempting to control the blood glucose
(BG) to near normal levels can lower the hemoglobin A1c
(HbA1c) and minimize long-term complications, but also
Frequent self-monitoring of BG (SMBG) is associated with
good control. But, SMBG gives children, parents, and practi-
tioners only glimpses of the glycemic excursions that children
with T1D experience in daily life.
A continuous glucose monitor (CGM) can provide near
real-time information about glucose levels and trends, as well
as alarms for projected dangerous glucose levels. With a very
small sensor that is inserted just under the skin and worn for
3–7 days, the sensor transmits the interstitial glucose values to
hildren with type 1 diabetes (T1D) are at significant
risk for the micro- and macrovascular complications of
a receiver that displays this information. Currently, CGMs are
not Food and Drug Aministration-approved to replace SMBG.
However, preliminary clinical data show that the information
provided by CGM technology enables patients to decrease
wide fluctuations in BG, as well as time in hypo- and hyper-
glycemic ranges.6This decrease in BG variability may
have important implications for decreasing the long-term
morbidity and mortality of diabetes.7–10CGM will also be an
integral component to closed-loop insulin delivery in a suc-
cessful artificial pancreas.
There remain some issues with accuracy and with the time
lag between the interstitial fluid glucose and the BG reading.
Practical considerations also initially prevented widespread
acceptance. A randomized, controlled study using an early
CGM version reported no improvement in glucose control or
severe hypoglycemia compared to usual care, and there were
significant problems with skin irritation, frequent skips, ex-
cessive alarms, and inaccurate readings.11A survey of the
1Division of Pediatric Endocrinology, University of Virginia Children’s Hospital; and
Pediatrics and4Behavioral Medicine Center, University of Virginia, Charlottesville, Virginia.
3Department of Pediatrics, Emory University, Atlanta, Georgia.
2Departments of Public Health Sciences and
DIABETES TECHNOLOGY & THERAPEUTICS
Volume 11, Number 6, 2009
ª Mary Ann Liebert, Inc.
treatment arm of this 200-subject trial revealed satisfaction
ratings of ‘‘less favorable than ‘neutral’’’in 73% ofthe children
and 81% of the parents.12These trials, however, used the
much more difficult-to-use form of continuous sensing tech-
nology. Recent studies with the most up-to-date CGM ver-
and have even had promising results in ‘‘closing the loop.’’15
Although some might assume that most people with T1D
would be highly interested in using a CGM, little has been
written about the level of acceptability of these devices in
different subgroups and families. Research in the United
Kingdom has shown that certain patient groups, including
those who do not trust physicians and those who question
the benefits of scientific research, are more reluctant to use
medical technology.16Which factors predict the degree of
interest in using CGM in parents of children with T1D remain
The present study investigated the level of interest, as well
as variables associated with more or less parental interest in
using a CGM. Our hypotheses were that the age of the child
and the degree of diabetes control would be associated with
the level of parental interest in CGM.
Subjects and Methods
Parents of children attending the University of Virginia
Children’s Hospital (Charlotesville, VA) and the Cincinnati
Children’s Hospital (Cincinnati, OH) diabetes clinics were
asked to participate in an anonymous online survey. In ad-
dition, a link to the online survey was provided at www.
childrenwithdiabetes.com, a website viewed by parents of
children with diabetes across the United States and around
the world. The survey was administered from February 2007
through June 2007. The introduction page to the survey stated
that consent to participate would be implied if the question-
if the respondent’s child had diabetes and if so, what type. If
the answer was ‘‘type 2’’ or ‘‘unknown,’’ the program termi-
nated the survey, and the participant was thanked for his or
Likert scale, where 1¼strongly disagree and 5¼strongly
agree. Thesurvey explored parentalattitudes regarding using
a CGM, as well as parental concerns about different aspects of
benefits and costs of a CGM, and degree of worry about vari-
ous aspects of their child’s diabetes, including long-term
complications and fear of hypoglycemia. Parents provided
demographic information including the child’s age, gender,
and country of residence. Diabetes-specific information was
also provided, including years since diagnosis, use of contin-
uous subcutaneous insulin infusion (CSII) (yes=no), frequency
of daily SMBG, and most recent HbA1c. The survey also as-
equipment were covered by insurance, as well as level of in-
terest if insurance did not cover the device. This analysis fo-
cuses on those with high interest if insurance were to pay for a
CGM, as this seems to be where the market is trending.
The primary outcome measure was whether or not the
parent expressed high interest in using a CGM if insurance
were to cover the device, with high interest defined as a score
of 4 or 5 on the Likert scale response for that question. The
proportion of respondents who expressed high interest was
compared across different clinical and demographic groups,
as well as parent opinions, using w2tests when sample size
was sufficiently large (a¼0.05). When comparisons involved
groups with small expected sample sizes, Fisher’s exact test
was used. The Cochran-Armitage test was used to assess for
any trend in the proportion with high interest for increasing
categories of age and number of times blood sugar was
interest groups (high vs. low) via a t test (not assuming equal
Atotal of503parents ofchildren (51% boys,49%girls)with
T1D responded to the online survey. Of these, 46 question-
for data analysis. The mean?SD age of the children was
10?4 years, and their average duration of diabetes was 4?3
years. Average reported HbA1c was 7.8?1.3%; values ran-
ged from 5.2% to 14.5%. Only 46% of parents believed that
their child’s TID was in ‘‘good control.’’ Parents reported that
SMBG was performed an average of eight times daily; 70% of
the children used CSII therapy. Ninety-six percent of parents
had heard of continuous glucose sensors, and 12% of the
children had previously used such a device. The great ma-
jority (>95%) of respondents were from the United States and
Over 90% of the parents indicated a strong interest in
having their child usea CGM,if insurance covered it.Without
insurance coverage, however, only 50% of those interested
thought that they would be able to afford the technology. In
the 12% of parents whose child had previously used a CGM,
96% continued to be interested in using a device. The vast
majority of parents believed that a CGM would benefit their
child in several ways. More than 90% of parents believed that
to decrease complications, and 95% of those studied thought
that a CGM would help them better see the effects of food and
exercise on glucose levels. However, only 80% indicated that
they would want their child to wear a CGM device all of the
time, as opposed to intermittently.
Only a very few parents (6%) believed that using a CGM
would increase their diabetes-related stress. Less than 2% of
parents indicated believing that they would be overwhelmed
by the large number of glucose readings provided by the
technology. Some (7%) were concerned that they would give
too much or too little insulin if they saw glucose readings
Several variables influenced the level of parental interest in
using a CGM (Table 1), including current treatment regimen.
Ninety-six percent of families who used CSII were interested
in a CGM, compared to 91% of those on multiple daily in-
jections (MDI) who wanted to start using CSII; this dropped
to 84% in families who were not interested in using CSII
(P¼0.0002). Ninety-six percent of families who checked BG
more than six times daily indicated high interest in CGM,
compared to 82% of families who checked BG three times or
less a day (P¼0.005).
In contrast to our hypotheses, parent-reported HbA1c level
was not associated with interest in CGM. Those with a high
374 KASHMER ET AL.
interest in CGM had a mean?SD HbA1c level of 7.8?1.3%,
whereas those with a low interest had a mean level?SD of
7.6?0.8%; this difference was not clinically nor statistically
significant (t test, P¼0.13). There were also no significant
differences in parental CGM interest based on child’s gender,
years since diagnosis, or previous use of a device (Table 1).
Additionally, the age of the child did not influence parental
interest in using a CGM; however, parents’ perception of their
child’s level of maturity did. For children 6–11 years old, 97%
wear a CGM were interested in trying one. Conversely, for
parents who did not believe their child in this age group was
mature enough to use CGM, only 68% were interested in
using it (P<0.0001). Similarly, in the 12–18-year-old age
group, 95% of parents who believed that their child was
mature enough to wear a CGM were interested in using one,
compared to 56% of parents who did not believe that their
adolescent was mature enough (P¼0.0017).
Parental level of concern or worry about their child’s dia-
betes and blood glucose control was significantly associated
with interest in using a CGM (Table 2). Ninety-five percent of
parents who indicated a high level of worry about the effects
of elevated BG on their child’s health were interested in CGM,
compared to 67% of parents who indicated a lower level of
worry (P¼0.0012). Ninety-five percent of parents who indi-
cated a high level of worry about hypoglycemia were inter-
ested in using a CGM, compared to 89% who indicated a
lower level of worry (P¼0.02). In addition, nearly all (98%)
parents whose child had problems with nocturnal hypogly-
cemia indicated high interest in using a CGM, compared to
92% of families for whom this was not a problem (P¼0.0065).
This study demonstrates that there is a high level of interest
in CGM in families of children with T1D. Although overall
interest was high, there were some variables that are associ-
ated with greater interest in this technology. First, familiarity
and interest in diabetes technology in general seem to predict
interest in using a CGM. Interest in using a CGM was highest
in parents whose children used CSII. The group next most
likely to want a CGM device were those parents whose chil-
dren used MDI but wanted to use CSII. Finally, the group that
was least interested in CGM were those parents of children
who used MDI and had no desire to start CSII therapy. To
date, most clinical trials in children using CGM have focused
on children already using CSII, likely because of an assump-
tion that there may be a technology barrier to overcome in
children who have not previously worn a medical device.
However, a recent study of children using MDI therapy
showed that CSII-naive children benefit equally in terms of
clinical improvements from using a CGM.14
Families who are currently performing SMBG greater than
six times daily were more interested in using a CGM than
those who only test one to three times daily, as well as those
who test four to six times daily. This may initially seem coun-
terintuitive. One might assume that those families who test
the least frequently would be most interested in a device that
has the potential to eventually replace SMBG and possibly
simplify patient diabetes management. However, our data
suggest that those who test the most frequently desire to ob-
tain even more data about glucose levels. A DirecNet Study
found similar results: children whose parents reported higher
scores on adherence scales, including BG checking, used their
CGM more frequently over the course of a 6-month study.17
These findings may be somewhat concerning: families who
are already having difficulty coping with demands of inten-
sive diabetes therapies, including SMBG, and who may po-
tentially reap the greatest benefits from CGM may not be
interested in this technology. This lack of interest may be due
values. Thus, there may be some psychological barriers to
overcome before certain families can be helped by CGM.
One of the most interesting findings in our study was the
impact of parental worry on the parent’s interest in using a
CGM. Significant differences in the level of interest in using a
CGM were found between those that agreed and those that
did not agree with the following statements: ‘‘I am worried
about the effects of high blood sugar on my child’s health,’’
‘‘I worry about my child having a low blood sugar reaction,’’
and ‘‘My child has problems with low blood sugar in the
middle of the night’’ (Table 2).
There is little in the diabetes literature about parental
worry.18,19However, from the time of their child’s diagnosis,
most parents are aware of the short-term and long-term
problems that their child may face as a result of his or her
diabetes. Those that worry the most about these problems
seem to be seeking additional assistance that might help their
Table 1. Child=Family Characteristics and Their
Association with High Parental Interest in a CGM
Years since diagnosis
Less than 2
6 or more
Checks blood sugar
Uses insulin pump
Parent has heard of a CGM
Child has worn a CGM
aHigh interest¼score of 4 or 5 on question regarding interest in
using a CGM if insurance were to cover the device.
bUnless noted, w2P value.
cCochran-Armitage trend test (exact P value).
dFisher’s exact test P value.
PREDICTORS OF PARENTAL INTEREST IN CGM375
the maturity level of their children were positively related to
the level of interest in using a CGM, while absolute age of the
child was not.
Our study has several methodological limitations. In us-
ing an anonymous online questionnaire, our goal was to
facilitate rapid collection of data in an area of pediatric dia-
betes that is changing rather quickly. However, this method
also prevents us from knowing how individual respondents
decided to complete the survey, that is, whether they re-
sponded to clinic advertisements or discovered the survey
independently while searching the Internet for diabetes in-
formation. In addition, our data relied on parental recall of
variables such as HbA1c levels and history of severe hypo-
glycemia. However, it was believed that the anonymous
nature of the survey would likely facilitate candid responses.
Although the survey instrument was not formally validated,
we relied on face validity. We focused our analysis on those
who were interested in using a CGM, provided insurance
covered the device. Currently, most insurance companies
have rather strict criteria regarding coverage of CGM de-
vices. Potentially relevant data on socioeconomic levels of
the families were not available, although certainly economic
factors currently likely play a large role in whether a family
can currently use a CGM. Unfortunately, our study did not
query diabetes knowledge, although this may have been an
important variable in predicting parental interest in using a
Thisstudy alsousedaquestionnaire accessibleonlythough
the World Wide Web, which presumes respondents have
access to and familiarity with a computer. This could intro-
this study indicated interest in using a CGM, which by itself is
an interesting finding with respect to making conclusions
about parents whoare familiarwitha computer. Nonetheless,
future studies should attempt to obtain a more representative
sample by collecting data via a non-computerized method,
such asatapediatric diabetesclinicorsummercamp.Because
significant differences in level of parental interest in CGM
were found in this motivated and fairly computer-savvy
population taking an online survey, we suggest that greater
differences are likely in the general population of families
with children with T1D.
Recently published research has shown that children and
young adults do not obtain the HbA1c-lowering benefits of
Table 2. Parental Opinions and Their Association with High Parental Interest in a CGM
I think that having blood sugar numbers continuously available might be
too much information
Do not agree
I think my child’s diabetes is under good control at this time
Do not agree
I am worried about the effects of high blood sugar on my child’s health
Do not agree
I am worried about the effects of low blood sugar on my child’s health
Do not agree
My child has problems with severely low blood sugar
Do not agree
My child has problems with low blood sugar in the middle of the night
Do not agree
I worry about my child having a low blood sugar reaction
Do not agree
My child worries about having a low blood sugar reaction
Do not agree
I believe my child is mature enough to wear a CGM
Do not agree
I don’t think my child would be interested in wearing a sensor that is
attached to his her body
Do not agree
aFor each statement: agree¼score of 4 or 5; do not agree¼score of 1, 2, or 3.
bHigh interest¼score of 4 or 5 on question regarding interest in a CGM if insurance were to cover it.
cUnless noted, w2P value.
dFisher’s exact test P value.
376 KASHMER ET AL.
using a CGM that their >24-year-old counterparts do.20The
Juvenile Diabetes Research Foundation Continuous Glucose
Monitoring Study Group also found that 8–14-year-olds and
15–24-year-olds wore their CGM devices 6 out of the 7 days of
the weekonly50%and30%ofthe time,respectively. This isin
contrast to those individuals 25 years and older, who wore
during the 6-month study. We propose that a level-of-interest
survey such as ours maybe one tool toassist in selecting those
families of young patients who are most interested and ready
to fully utilize a CGM.
This study helps to confirm the assumption of many pe-
diatric endocrinologists: there is a high degree of interest in
CGM devices in families of children with T1D. More impor-
tantly, though, these results suggest that particular popula-
tions may be more interested and therefore may be willing to
put the most effort into using a new form of diabetes tech-
data mayalso prove useful inhelping toidentify thosegroups
who are not yet ready to initiate new diabetes technology. In
identifying barriers to optimal use of a CGM, strategies to
overcome these barriers may be developed.
We would like to thank Nancy Morwessel, C.N.P., M.S.N.,
C.D.E., at the University of Cincinnati and Jeff Hitchcock of
www.childrenwithdiabetes.com for helping to bring subjects
to our questionnaire. Funding was provided by the National
Institutes of Health (grant T32DK007320), Abbott Diabetes
Care, and the Juvenile Diabetes Research Foundation.
Author Disclosure Statement
Diabetes Care and consulting=speaking fees from Abbott
Diabetes Care and Merck & Co., Inc. W.C. has received
grants to support research from Abbott Diabetes Care and
consulting=speaking fees from Abbott Diabetes Care, Smith’s
Medical, and Indevus Pharmaceuticals, Inc. L.K., M.G., S.E.,
and N.B. have no relevant financial relationships to disclose.
1. Nathan DM, Cleary PA, Backlund JY, Genuth SM, Lachin
JM, Orchard TJ, Raskin P, Zinman B; Diabetes Control and
Complications Trial=Epidemiology of Diabetes Interventions
and Complications (DCCT=EDIC) Study Research Group:
Intensive diabetes treatment and cardiovascular disease in
patients with type 1 diabetes. N Engl J Med 2005;353:2643–
2. Cryer PE, Davis SN, Shamoon H: Hypoglycemia in diabetes.
Diabetes Care 2003;26:1902–1912.
3. The effect of intensive treatment of diabetes on the devel-
opment and progression of long-term complications in
insulin-dependent diabetes mellitus. The Diabetes Control
and Complications Trial Research Group. N Engl J Med
4. Bulsara MK, Holman CDJ, Davis EA, Jones TW: The impact
of a decade of changing treatment on rates of severe hypo-
glycemia in a population-based cohort of children with type
1 diabetes. Diabetes Care 2004;27:2293–2298.
5. Cox DJ, Kovatchev BP, Julian DM, Gonder-Frederick LA,
Polonsky WH, Schlandt DG, Clarke WL: Frequency of
severe hypoglycemia in insulin-dependent diabetes mellitus
predicted from self-monitoring blood glucose data. J Clin
Endocrinol Metab 1994;79:1659–1662.
6. Garg S, Zisser H, Schwartz S, Bailey T, Kaplan R, Ellis S,
Jovanovic L: Improvement in glycemic excursions with a
transcutaneous, real-time continuous glucose sensor: a ran-
domized controlled trial. Diabetes Care 2006;29:44–50.
7. The relationship of glycemic exposure (HbA1c) to the risk
of development and progression of retinopathy in the
Diabetes Control and Complications Trial. Diabetes 1995;
8. Monnier L, Mas E, Ginet C, Michel F, Villon L, Cristol JP,
Colette C: Activation of oxidative stress by acute glucose
fluctuations compared with sustained chronic hyperglyce-
mia in patients with type 2 diabetes. JAMA 2006;295:1681–
9. Brownlee M, Hirsch I: Glycemic variability: a hemoglobin
10. Hirsch I: Glycemic variability: it’s not just about A1C any-
more! Diabetes Technol Ther 2005;7:780–783.
11. Chase HP, Beck R, Tamborlane W, Buckingham B, Mauras
N, Tsalikian E, Wysocki T, Weinzimer S, Kollman C, Ruedy
K, Xing D: A randomized multicenter trial comparing the
GlucoWatch Biographer with standard glucose monitor-
ing in children with type 1 diabetes. Diabetes Care 2005;28:
12. Diabetes Research in Children Network (DirecNet) Study
Group: Youth and parent satisfaction with clinical use of the
GlucoWatch G2 Biographer in the management of pediatric
type 1 diabetes. Diabetes Care 2005;28:1929–1935.
13. Wilson DM, Buck RW, Tamborlane WV, Chase HP, Fox LA,
Ruedy KJ, Tsalikian E, Weinzimer SA; DirecNet Study
Group: Accuracy of the FreeStyle Navigator continuous glu-
cose monitoring system in children with type 1 diabetes.
Diabetes Care 2007;30:59–64.
14. Weinzimer S, Xing D, Tansey M, Fiallo-Scharer R, Mauras N,
Wysocki T, Beck R, Tamborlane W, Ruedy K: FreeStyle
Navigator continuous glucose monitoring system use in
children with type 1 diabetes using glargine-based multiple
daily dose regimens: results of a pilot trial Diabetes Research
in Children Network (DirecNet) Study Group. Diabetes Care
15. Weinzimer S, Steil GM, Dziura J, Kurtz N, Tamborlane WV:
Fully automated closed-loop insulin delivery versus semi-
automated hybrid control in pediatric patients with type 1
diabetes using an artificial pancreas. Diabetes Care 2008;31:
16. Calnan M, Montaner D, Horne R: How acceptable are in-
novative healthcare technologies? A survey of public beliefs
and attitudes in England and Wales. Social Sci Med 2005;
17. Diabetes Research in Children Network (DirecNet) Study
Group: Psychological aspects of continuous glucose moni-
toring in pediatric type 1 diabetes. Pediatr Diabetes 2006;7:
18. Faulkner MS, Clark FS: Quality of life for parents of children
and adolescents with type 1 diabetes. Diabetes Educ 1998;24:
19. Vandagriff JL, Marrero DG, Ingersoll GM, Fineberg NS:
Parents of children with diabetes: what are they worried
about? Diabetes Educ 1992;18:299–302.
20. The Juvenile Diabetes Research Foundation Continuous
Monitoring Study Group, Tamborlane WV, Beck RW, Bode
PREDICTORS OF PARENTAL INTEREST IN CGM377
BW, Buckingham B, Chase HP, Clemons R, Fiallo-Scharer
R, Fox LA, Gilliam LK, Hirsch IB, Huang ES, Kollman C,
Kowalski AJ, Laffel L, Lawrence JM, Lee J, Mauras N,
O’Grady M, Ruedy KJ, Tansey M, Tsalikian E, Weinzimer S,
Wilson DM, Wolpert H, Wysocki T, Xing D: Continuous
glucose monitoring and intensive treatment of type 1 dia-
betes. N Engl J Med 2008;359:1464–1476.
Address reprint requests to:
Linda Gonder-Frederick, Ph.D.
University of Virginia Behavioral Medicine Center
P.O. Box 800223
Charlottesville, VA 22908
378KASHMER ET AL.