Pediatric Diabetes

Aims. This study aimed to identify the quantity and range of protein, fat, and carbohydrate consumed in meals and snacks in children with Type 1 diabetes (T1D), and to explore associations between the variability in fat and protein intakes with the glycemic outcomes. Methods. This was a cross-sectional dietary study of children 6–18 years attending pediatric diabetes service in Australia. Three-day weighed food records were analyzed for the macronutrient intake. Impacts of dietary intake on glycemic outcomes were explored. Results. Forty-eight children (63% male) aged 11.7 ± 2.9 (mean ± SD) with HbA1c 6.7 ± 1.1% (mmol/mol), BMI Z-score 0.51 ± 0.83, and daily insulin dose 0.99 units/kg completed 3-day weighed food records. Mean intakes at breakfast were 47-g carbohydrate, 15-g protein, and 12-g fat. Lunch: 49-g carbohydrate, 19-g protein, and 19-g fat. Dinner: 57-g carbohydrate, 33-g protein, and 26-g fat. Fifty-five percent (n = 80) of the dinner meals met criteria for a high-fat, high-protein (HFHP) meal. In a subset (n = 16) of participants, exploratory analysis indicated a trend of reduced %TIR (58%) in the 8 hr following HFHP dinner, compared to %TIR (74%) following non-HFHP dinner ( p = 0.05 ). Seventy-eight percent of the participants aged 12–18 years intake at dinner varied by more than 20-g fat or more than 25-g protein. There was no association between the variability in fat and protein intake at dinner with HbA1c. Saturated fat contributed to 14.7% (±3.0) of participants energy intake. Conclusions. Children with T1D frequently consume quantities of fat and protein at dinner that have been shown to cause delayed postprandial hyperglycemia. HFHP dinners were associated with the reduced %TIR over 8 hr, presenting an opportunity for insulin-dose adjustments. Future research that explores the meal dietary variability with postprandial glycemia in this population is needed. Excessive intake of the saturated fat highlights the need for dietary interventions to reduce CVD risk. This trial is registered with ACTRN12622000002785.

Introduction. The landscape of childhood diabetes has evolved and addressing the knowledge gaps in non-Type 1 diabetes mellitus are key to accurate diagnosis. Objectives. A national surveillance study was completed between 2006 and 2008 and then repeated between 2017 and 2019 to describe Canadian incidence trends and clinical characteristics of non-Type 1 diabetes mellitus. Methods. We prospectively tracked new cases of non-Type 1 diabetes mellitus in children <18 years of age between June 1, 2017 and May 31, 2019. For each reported new case, a detailed questionnaire was completed, and cases were classified as Type 2 diabetes mellitus, medication-induced diabetes (MID), monogenic diabetes, or “indeterminate.” Minimum incidence rates and 10-year incidence trends of non-Type 1 diabetes mellitus and its subtypes were calculated. Results. 441 cases of non-Type 1 diabetes mellitus were included (Type 2 diabetes mellitus = 332; MID = 52; monogenic diabetes = 30; indeterminate = 27). Compared to 10 years ago, the incidence of MID and monogenic diabetes remained stable, while Type 2 diabetes mellitus increased by 60% ( p < 0.001 ) overall and by 37% ( p = 0.005 ) and 50% ( p = 0.001 ) in females and males, respectively. Type 2 diabetes mellitus incidence increased by 1.5 times in Indigenous ( p < 0.001 ) and doubled in Asian ( p = 0.003 ) children. Conclusions. Canadian incidence rates of childhood-onset Type 2 diabetes mellitus have significantly increased. Further research, policy, and prevention efforts are needed to curb rising rates of youth onset Type 2 diabetes mellitus.

Aim. The effect of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection on the pediatric occurrence of type 1 diabetes (T1D) is inconclusive. We aimed to assess associations between seroprevalences of the distinct anti-SARS-CoV-2 antibodies and T1D occurrence in children and adolescents. Methods. This multicenter prospective observational cohort comprised children diagnosed with T1D between October 2020 and July 2022 and unrelated children who performed endocrine tests (control group) in a 1 : 3 ratio. Anti-SARS-CoV-2 antibodies, including anti-S, anti-N, and neutralizing antibodies, were assessed in each group. Results. The cohort included 51 children with T1D and 182 children in the control group. The median (interquartile range) age was 11.4 (8.2, 13.3) years, with 45% being female. Increases were not observed in the seroprevalence of any of the anti-SARS-CoV-2 antibodies among the children with new-onset T1D compared to the control group. Among the T1D group, anti-S seroprevalence was higher among those without diabetic ketoacidosis (DKA) than in those with DKA upon T1D diagnosis (72% vs. 42%, p = 0.035 ). After adjustment to vaccination status, this difference was not statistically significant. Additionally, anti-N antibodies and neutralizing antibodies did not differ between the DKA and the non-DKA groups. None of the anti-SARS-CoV-2 antibodies were associated with any of the glycemic parameters. Conclusions. This study is the first to assess several distinct anti-SARS-CoV-2 antibodies in new-onset T1D, and our findings do not support an association between SARS-CoV-2 infection and the occurrence of T1D in children and adolescents. Since autoimmunity may emerge years after a viral infection, we recommend conducting follow-up epidemiological studies to assess whether there is a change in the incidence of T1D following the SARS-CoV-2 pandemic.

Introduction. The underlying pathophysiology of diabetes mellitus after acute pancreatitis is unknown and overall risk of developing diabetes postacute pancreatitis in children is understudied. The objective of our study was to describe the frequency of islet cell autoimmunity and abnormal glucose testing in pediatric patients in the year following their index case of acute pancreatitis. Materials and Methods. Data were obtained from a single-center observational cohort study of patients with their first episode of acute pancreatitis. Islet cell autoantibody titers were measured on stored plasma collected from acute pancreatitis diagnosis, at 3 months and at 12 months postacute pancreatitis attack. Abnormal glucose testing was defined as the presence of prediabetes or diabetes, as defined by American Diabetes Association criteria. Results. Eighty-four patients with acute pancreatitis and islet cell autoantibody data were included, 71 had available glucose measures. Median age at first acute pancreatitis attack was 14 years (IQR 8.7–16.3) and 45/84 (54%) were females. Twenty-four patients (29%) were positive for at least one of four islet cell autoantibodies (IAA, GADA, IA-2A, and ZnT8A) and 6 (7%) had two or more positive islet cell autoantibodies. Nineteen patients out of 71 (27%) had abnormal glucose testing at or postacute pancreatitis diagnosis. A higher proportion (37%, 7/19) with abnormal glucose testing had severe acute pancreatitis compared to those with normal glucose testing (13%, 7/52) ( p = 0.04 ). Patients with normal glucose testing were more likely to be positive for one or more islet cell autoantibodies (31%, 16/52) compared to those with abnormal glucose testing (0%, 0/19) ( p = 0.004 ). Conclusions. Islet cell autoimmunity is more common in children after their index acute pancreatitis attack (29%) than in the general population (7%–8%). While the frequency of prediabetes and diabetes postacute pancreatitis is high, other mechanisms besides islet cell autoimmunity are responsible.

Background. Youth with Type 1 diabetes (T1D) who are Black, Hispanic, or lower socioeconomic status (SES) have lower rates of diabetes device use, higher hemoglobin A1c (HbA1c), and higher rates of diabetic ketoacidosis (DKA). However, the associations of individual-level social determinants of health (SDoH) and neighborhood-level factors with device use and clinical outcomes are unknown. Area deprivation index (ADI) is a neighborhood level measure of SES reported in deciles (range 1–10 with 10 representing most deprived neighborhood). Methods. We evaluated the association of ADI and other SDoH factors with pump/continuous glucose monitor (CGM) use, HbA1c, and DKA in 1,461 youth with T1D (50% female, age 12.8 ± 3.6 years, HbA1c 8.7 ± 2.1%, 52% pump, 70% CGM) seen between October 1, 2020 and September 30, 2021 at a large pediatric diabetes center. Multiple logistic regression and multiple linear regression analyses were used to determine statistically significant associations adjusting for potential confounders. Results. Youth were less likely to use an insulin pump if they lived in a higher ADI neighborhood, were Black or Hispanic, had Medicaid or were uninsured, or received government assistance (e.g., Supplemental Security Income, Supplemental Nutritional Assistance Program). Youth were less likely to use a CGM if they lived in a higher ADI neighborhood, were Black or Hispanic, had Medicaid or were uninsured. Youth had higher risk of DKA event in the past year if they used government assistance, whereas pump and CGM use were associated with lower DKA risk. HbA1c (%) increased by 0.09 (95% CI: 0.05, 0.13) per unit increase in ADI. HbA1c was 0.62 lower (95% CI: −0.82, −0.42) in pump users vs. nonusers and 0.78 lower (95% CI: −0.99, −0.56) in CGM users vs. nonusers. Conclusions. Interventions that tailor care plans to address SDoH in families living in deprived neighborhoods may be needed to increase successful technology uptake, optimize HbA1c, and prevent DKA.

Aims. Assessment of the glycemic outcomes of increasing and splitting mealtime insulin doses for mixed fat and protein meals in pediatric patients with type 1 diabetes mellitus (T1DM) using multiple daily injection regimen and comparing the effects of regular insulin and fast-acting insulin on glycemic outcomes following those meals. Methods. This single-center, randomized, cross-over trial included 43 children and adolescents with T1DM randomly assigned to receive three interventional insulin doses for lunch meals over 3 consecutive days; Intervention A (100% insulin-to-carbohydrate ratio (ICR) dose given as premeal insulin lispro with an additional insulin sensitivity factor-calculated correction dose after 3 hr), Intervention B (130% ICR dose split into 60% premeal insulin lispro and 40% postmeal insulin lispro after 30 min), and Intervention C (130% ICR dose split into 60% premeal insulin lispro and 40% postmeal regular insulin after 30 min). The test meal consisted of two slices of pizza (weight: 150 g, carbohydrates: 40 g, fat: 15 g, protein: 20 g, and calories: 380 kcal). Postprandial blood glucose levels were monitored for 6 hr. Results. There were no significant differences in postprandial blood glucose excursions following the three interventions. However, Intervention C had a significantly lower late (3–6 hr) blood glucose area under the curve ( p = 0.01 ). Postprandial hypoglycemia developed in 12 participants (27.9%) following Interventions A and B and in 17 participants (39.5%) following Intervention C ( p = 0.32 ). Conclusions. Using regular insulin as a postmeal portion of increased and split insulin doses provided better late postprandial glycemic outcomes following mixed fat and protein meals. However, the amount of additional insulin used needs optimization to reduce the frequency of postprandial hypoglycemia. This trial is registered with NCT04783376.

Objective. To further evaluate glycemic outcomes during the observational extension phase of the Continuous Glucose Monitoring (CGM) Intervention for Teens and Young Adults randomized clinical trial (RCT). Subjects and Methods. Following a 26-week RCT comparing CGM with blood glucose monitoring (BGM) in 153 adolescents and young adults aged 14 to <25 years old with suboptimally controlled type 1 diabetes, 70 (89%) participants in the BGM group initiated use of CGM (referred to as BGM–CGM cohort), and 70 (95%) participants in the CGM group continued to use of CGM (CGM–CGM cohort) for an additional 26 weeks. Results. In the CGM–CGM cohort, mean hemoglobin A1c (HbA1c) decreased from 8.9% ± 0.9% (74 ± 9.8 mmol/mol) at randomization to 8.3% ± 1.3% (67 ± 14.2 mmol/mol) at 52 weeks ( p < 0.001 ); however, significant improvement in time in target range (TIR) 70–180 mg/dL was not observed from prerandomization (38% ± 13%) to 52 weeks (41% ± 18%). Median percent time <70 mg/dL decreased from 3.0% before randomization to 1.1% at 52 weeks ( p < 0.001 ). In the BGM–CGM cohort, mean HbA1c decreased from 8.9% ± 1.2% (74 ± 13.1 mmol/mol) before CGM initiation to 8.5% ± 1.3% (69 ± 14.2 mmol/mol) after 26 weeks of CGM use ( p < 0.001 ) and mean TIR increased from 34% ± 12% to 38% ± 15% ( p = 0.01 ). The median percent time <70 mg/dL decreased from 3.3% before CGM initiation to 1.2% after 26 weeks of CGM use ( p < 0.001 ). No participants discontinued CGM use during the extension phase. Conclusions. This further evaluation of CGM supports the findings of the preceding RCT that use of CGM improves glycemic control and reduces hypoglycemia in adolescents and young adults with type 1 diabetes. This trial is registered with NCT03263494.

Background. Racial disparities are well described in glycemic outcomes in youth with Type 1 diabetes mellites (T1D). Hemoglobin A1c (HbA1c) has some limitations in comparing glycemia across patient groups as there are individual variations in mean glucose and HbA1c. Objective. This study aimed to compare glycemic metrics obtained from (Dexcom G6) continuous glucose monitor (CGM) device with HbA1c levels controlling for race, age, duration of diabetes, race, insurance status, and insulin pump use with glycemic control. Subjects and Methods. Data analyzed included 188 patients, majority non-Hispanic White (NHW) (n = 147, 78.2%) and majority privately insured (n = 147, 78.2%). Half of the patients were using insulin pumps, (n = 94, 50.0%) and approximately half were female. Median age was 16.6 (interquartile range: 14.2–18.2) years old with a median age of diabetes diagnosis at 9.3-years old. Results. Significant differences were observed between NHW and non-Hispanic Black (NHB) patients in terms of HbA1c, 90-day mean glucose, and 90-day time >250 mg/dL (>13.9 mmol/L) (7.6% vs. 9.2%, 181 mg/dL vs. 220 mg/dL, and 16.3% vs. 34.7%, respectively, p < 0.001 for all comparisons). Multiple linear regression analysis was performed to predict the influence of age, duration of diabetes, race, insurance status, and insulin administration on glycemic outcomes. Regression analysis revealed significant equations for all glycemic outcomes, demonstrating a strong correlation ( p < 0.0001 , p = 0.0001 , and p < 0.0001 , respectively). However, after controlling for these variables, only race and duration of diabetes remained independently associated with glycemic outcomes, suggesting that these factors strongly influence glycemic control independent of age, sex, insurance, and pump use. Conclusion. Even in a subset of youth with T1D using CGM with high rates of insulin pump use, disparities in glycemic outcomes persist. When evaluating glycemic outcomes, race remained a significant cofactor despite controlling for age, duration of diabetes, sex, insurance status, and insulin administration type. These results add to the existing literature, and demonstrate race remains strong predictor of glycemic outcomes.

Aim. The trajectories of the hypoglycemia awareness status (HAS) have not yet been studied in children and adolescents with Type 1 diabetes (T1D). Methods. This 2-year follow-up study included children and adolescents with T1D aged 6‒20 years old and using flash glucose monitoring. The HAS of each participant was determined by the Gold score and assessed at three time points, along with clinical data. The trajectories based on HAS progression over time were identified, and a logistic regression analysis was performed to compare their characteristics. Results. Among the 255 participants, we identified four HAS trajectories (T1–T4). T1: normal awareness of hypoglycemia (NAH) maintained over time (n = 82, 29%); T2: NAH recovered during follow-up (n = 40, 18%); T3: impaired awareness of hypoglycemia (IAH) developed during follow-up (n = 28, 12.4%); T4: IAH maintained over time (n = 59, 21%). Sixteen participants (7%) displayed no identifiable trajectory. Participants belonging to the T3 group were younger. Following a specific trajectory defined the risk of developing future severe hypoglycemia. Conclusions. HAS changed in a significant proportion of pediatric people with T1D over time. Participants with a trajectory toward IAH were younger. Frequent HAS assessments may help to improve hypoglycemia risk management, especially in young children with T1D.

Objective. The use of hybrid closed-loop insulin delivery systems, specifically the t:slim X2 insulin pump with Control IQ (CIQ), has demonstrated improvement in glycemic control in clinical trials and real-world settings. We sought to describe changes in glycemic control with use of CIQ in minority and nonminority youth. Research Design and Methods. This was a retrospective study of youth with type 1 diabetes (T1D) using CIQ over a 12-month period. Medical record data, pump data, and hemoglobin A1c (HbA1c) were collected from the visit prior to starting CIQ and at each clinic visit up to 12 months after starting CIQ. Continuous glucose monitor (CGM) data and HbA1c trajectory over time were compared to baseline and between minority and nonminority youth. Results. The study included 136 patients of whom 21 were minority youth (non-Hispanic Black and Hispanic), 50% were male, with median age of 13.3y, and median diabetes duration of 4.9y. After starting CIQ, baseline median HbA1c for the nonminority group decreased from 7.8% to 7.1% ( p < 0.001 ), baseline median HbA1c for minority youth decreased from 9.8% to 7.8% ( p = 0.03 ), and the percentage of patients meeting target HbA1c <7% increased from 26% to 45%. Both nonminority and minority youth had a significant increase in time in range and decrease of average CGM glucose ( p < 0.05 ). Conclusions. HbA1c levels decreased in both minority and nonminority youth within 12 months of starting CIQ, and more patients reached the HbA1c target of less than 7%. Disparities in HbA1c between minority and nonminority youth remained and additional studies are warranted to improve this.

This study aimed to explore the attitudes of teachers toward type 1 diabetes (T1D) and its management. Teachers working in kindergartens and schools (N = 30) participated in audio-recorded, semi-structured interviews (three focus groups and 20 individual interviews) that were transcribed and analyzed using thematic analysis. We used the theory of the three components of attitude as a framework for the analysis. The three components of attitude emerged during the analysis: knowledge, positive and negative emotions, approaches, and opinions toward diabetes and its management and behavior. The main theme of knowledge included knowledge about diabetes in general and its management. Besides medical treatment, alternative treatment possibilities were mentioned by the participants. The affective component revealed empathy, integrating, and segregating approaches toward children living with diabetes. The behavior component revealed how teachers contribute to the care and integration of children with diabetes in schools. They support children with diabetes by the virtue of their profession. For example, they teach them health awareness and support their integration through peer education and sensitization. The findings indicated that, in addition to diabetes management tasks, teachers could help children with T1D by tutoring them and their peers about health awareness and T1D acceptance.

Background. Youths with type 1 diabetes transitioning from pediatric to adult care are known to experience significant glycemic excursions and medical complications. Diabetes distress and transition readiness are two potentially related constructs involved in this transition process, but the relationship between them has not been extensively studied. Hypothesis. Lower diabetes distress is associated with increased transition readiness among youths with type 1 diabetes transitioning to adult care. Subjects. One hundred one adolescents and emerging adults with type 1 diabetes transitioning to adult care complete data in 63 study participants. Methods. In this cross-sectional study, we collected diabetes distress scale scores (via T1-DDS) and transition readiness scores (via Am I ON TRAC) at the last pediatric diabetes visit. We fitted regression models to estimate the relationship between T1-DDS scores and ON TRAC scores. Results. The total mean T1-DDS score was associated with ON TRAC knowledge score (β = −2.73, 95% CI −4.41,−1.06, p = 0.002 ), behavior score (β = −2.61, 95% CI −4.39,−0.84, p = 0.005 ), and transition readiness indicator (β = −0.18, −0.34,−0.01, p = 0.03 ). Multiple T1-DDS subscales were associated with ON TRAC knowledge score: powerlessness, management distress, negative social perceptions, eating distress, physician distress, and family/friend distress. Multiple T1-DDS subscales were also associated with ON TRAC behavior score: management distress, negative social perceptions, eating distress, and family/friend distress. Conclusions. Diabetes distress and transition readiness have an inversely proportional relationship in youths with type 1 diabetes transitioning to adult care. Targeting diabetes distress may also improve transition readiness (and vice versa) in this population.

Background. Quality of life (QoL) is extensively used as an outcome in the studies of children with diabetes. The interest in measuring QoL in relation to clinical treatment and interventions has led to an increase in the development and use of QoL measures. The vast number of available instruments can be a barrier for establishing evidence and can be overwhelming for clinicians and researchers who are interested in measuring QoL of children with diabetes. Aim. As a first step for reaching consensus, we aimed to provide a comprehensive overview of the application of QoL instruments used in children (2–18 years old) with diabetes. Method. A literature search for studies published from inception to January 2022 was conducted in the databases MEDLINE (Ovid), Embase (Ovid), PsycInfo (EBSCO), CINAHL (EBSCO), and ERIC (EBSCO). The search strategy combined the key concepts of “quality of life”, “diabetes”, and “children or adolescents”. Studies were found eligible if (1) the population was below 19 years of age; (2) had diabetes mellitus; and (3) a quantitative measure of QoL was used. Results. 3,775 unique articles were retrieved in the literature search and, across 503 articles included for synthesis, 67 QoL instruments were identified. The instruments were classified by i.a. population age, continent, use of pre–post measure, self-report or proxy, and type of diabetes. Conclusion. The extensive number of QoL instruments that are used for children with diabetes constitutes a substantial barrier for establishing evidence in relation to QoL in this research area.

Context. Type 1 diabetes (T1D) is a heterogeneous disease affecting the islets and the exocrine pancreas. How the topographical distribution of the involved tissue lesions correlates with the patient phenotype and pancreas functions is uncertain. Objective. To perform a longitudinal characterization of the pancreas in patients with new-onset T1D and investigate the correlations between magnetic resonance imaging (MRI) parameters and pancreatic functions during the first year postdiagnosis. Methods. Thirty-one pediatric patients with new-onset T1D and 29 retrospective age-, body mass index-, and sex-matched controls were included in the study. Following hypotheses were investigated: (H1) the value of pancreas volume (PV) parameters in T1D and in controls, (H2) the association between MRI parameters and markers of pancreatic functions, (H3) the ability of MRI parameters to predict glucose homeostasis, (H4) the longitudinal evolution of MRI parameters and glucose homeostasis, per-organ (whole pancreas) and per-subregion (head, body, and tail). Results. Patients with new-onset T1D demonstrated a significant decrease of PV at diagnosis compared to controls (−45%), with prepubertal patients having increased pancreas atrophy (+25%) (H1). PV parameters were correlated with C-peptide, and trypsinogen (PVTail and PVHead, respectively). Biparametric regression models including MRI parameters predicted pancreas functions during the first year postdiagnosis (H3). Longitudinal evolution of PV parameters at 1 year postdiagnosis was correlated with PV at diagnosis (R = −0.72) but not with markers of glucose homeostasis (H4). Conclusion. Our study shows that longitudinal analysis of pancreases of children with T1D using multiparametric MRI improve the understanding of T1D heterogeneity both in the context of its onset and its evolution.

Background. Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of childhood diabetes. However, the influence of demographic factors on presentation are not well-defined. Methods. We included children from 12 centers who were <18 years with DKA (glucose > 300 mg/dL, serum pH < 7.25, or serum bicarbonate <15 mEq/L) enrolled in the Pediatric Emergency Care Applied Research Network (PECARN) Fluid Therapies Under Investigation in DKA (FLUID) Trial. Data were also collected for children who presented to the centers during the enrollment period but were not enrolled due to disease or treatment-related reasons. We compared demographic, clinical, and biochemical findings among children with newly and previously diagnosed diabetes and children in different age groups. Results. Of the 1,679 DKA episodes in 1,553 children, 799 (47.5%) episodes occurred in children with newly diagnosed diabetes and 396 (23.6%) were severe (pH < 7.1). Newly diagnosed children <6 years of age were not more likely to have severe DKA in terms of pH, but had more severe hypocarbia and higher blood urea nitrogen levels, factors previously associated with the risk of cerebral injury. Lower socioeconomic status (SES) (based on family income and maternal education level) were associated with more severe DKA in new onset children, and recurrent DKA in the previously diagnosed children. Conclusions. Greater efforts are needed to identify the children with diabetes early and to prevent recurrent DKA, particularly among children in low-SES groups. Young children with DKA may need more intensive monitoring due to higher risk of cerebral injury.

Objective. To evaluate patterns of continuous glucose monitor (CGM) use and perceptions of quality of life in adolescents/young adults with type 1 diabetes (T1D) after using CGM for up to 52 weeks in the CGM Intervention in Teens and Young (CITY) Adults randomized clinical trial (RCT). Subjects and Methods. Participants with T1D were initially randomized 1 : 1 to use of CGM or blood glucose meter (BGM) for 26 weeks. Following the RCT, participants in the BGM group initiated CGM (BGM–CGM cohort) and participants in the CGM group continued CGM (CGM–CGM cohort) for another 26 weeks. Problem Areas in Diabetes Survey-Pediatric Version (PAID-peds), Glucose Monitoring Satisfaction Survey (GMSS), Hypoglycemia Confidence Scale (HCS), Diabetes Technology Attitudes (DTA), Pittsburgh Sleep Quality Index (PSQI), Benefits of CGM, and Burdens of CGM were completed at baseline, 26 and 52 weeks. Results. In both cohorts, >70% of participants were wearing CGM > 5 days/week at 52 weeks; 5% discontinued CGM. The majority used the mobile app to receive glucose data. Adolescents (14 to <19 years) were more likely to use SHARE features than young adults (80% versus 41%). CGM–CGM participants had significantly higher scores on GMSS, DTA, and HCS at 52 weeks compared with baseline, and reported higher benefit and lower burden perceptions than at baseline. Similar results were observed for the BGM–CGM cohort. Conclusions. Improvements in self-reported measures were observed in adolescents and young adults using CGM. As CGM use is also associated with better glycemic control, utilizing CGM may contribute to improving both medical outcomes and emotional health.

Objective. We evaluated the association of household food insecurity (FI) with cognition in youth and young adults with type 1 diabetes (T1D) or type 2 diabetes (T2D). Design. In this cross-sectional study, age-adjusted scores for composite fluid cognition, and sub-domain scores for receptive language and inhibitory control and attention, were stratified by diabetes type using linear regression, with FI in the past year as the predictor, controlling for covariates. Tests for processing speed, inhibitory control/attention, working memory, episodic memory, and cognitive flexibility were administered to measure the composite fluid cognition score. The NIHT-CB Picture Vocabulary Test was used to assess the crystallized cognition score, and rapid identification of congruent versus noncongruent items was used to assess inhibitory control and attention score. Setting. The SEARCH for Diabetes in Youth study is representative of five U.S. states. Participants. Included 1,574 youth and young adults with T1D or T2D, mean age of 21 years, mean diabetes duration of 11 years, 51% were non-Hispanic white, and 47% had higher HbA1c levels (>9% HbA1c). Results. Approximately 18% of the 1,240 participants with T1D and 31% of the 334 with T2D experienced FI. The food-insecure group with T1D had a lower composite fluid cognition score (β = −2.5, 95% confidence interval (CI) = −4.8, −0.1) and a lower crystallized cognition score (β = −3.4, CI = −5.6, −1.3) than food-secure peers. Findings were attenuated to non-significance after adjustment for demographics. Among T2D participants, no associations were observed. In participants with T1D, effect modification by glycemic levels was found in the association between FI and composite fluid cognition score but adjustment for socioeconomic characteristics attenuated the interaction ( p = 0.0531 ). Conclusions. Food-insecure youth and young adults with T1D or T2D did not have different cognition compared to those who were food-secure after adjustment for confounders. Longitudinal research is needed to further understand relations amongst these factors.

Given the differential risk of type 1 diabetes (T1D) in offspring of affected fathers versus affected mothers and our observation that T1D cases have differential DNA methylation near the imprinted DLGAP2 gene compared to controls, we examined whether methylation near DLGAP2 mediates the association between T1D family history and T1D risk. In a nested case–control study of 87 T1D cases and 87 controls from the Diabetes Autoimmunity Study in the Young, we conducted causal mediation analyses at 12 DLGAP2 region CpGs to decompose the effect of family history on T1D risk into indirect and direct effects. These effects were estimated from two regression models adjusted for the human leukocyte antigen DR3/4 genotype: a linear regression of family history on methylation (mediator model) and a logistic regression of family history and methylation on T1D (outcome model). For 8 of the 12 CpGs, we identified a significant interaction between T1D family history and methylation on T1D risk. Accounting for this interaction, we found that the increased risk of T1D for children with affected mothers compared to those with no family history was mediated through differences in methylation at two CpGs (cg27351978, cg00565786) in the DLGAP2 region, as demonstrated by a significant pure natural indirect effect (odds ratio (OR) = 1.98, 95% confidence interval (CI): 1.06–3.71) and nonsignificant total natural direct effect (OR = 1.65, 95% CI: 0.16–16.62) (for cg00565786). In contrast, the increased risk of T1D for children with an affected father or sibling was not explained by DNA methylation changes at these CpGs. Results were similar for cg27351978 and robust in sensitivity analyses. Lastly, we found that DNA methylation in the DLGAP2 region was associated ( P < 0.05 ) with gene expression of nearby protein-coding genes DLGAP2, ARHGEF10, ZNF596, and ERICH1. Results indicate that the maternal protective effect conferred through exposure to T1D in utero may operate through changes to DNA methylation that have functional downstream consequences.

Background. After-hours triage of pediatric patients by trained nurses improves consistency of triage decisions, access, and quality of care, and decreases burden on physicians on-call. There is a lack of published experience with this approach in the pediatric diabetes population. Methods. An after-hours call service was established in September 2019 in our large urban pediatric teaching hospital. Barton Schmitt guidelines, which are widely accepted as the standard for telephone triage care, were modified to include institution specific diabetes management protocols. We analyzed demographics, reasons for call, clinical presentation to the emergency room, and clinical disposition of the callers. Results. The after-hours call service handled 70% of calls without physician involvement. There were no patients triaged to home care who subsequently required an emergency room visit or hospitalization. Patients who called the after-hours nurse line prior to coming to the emergency room were less sick and were discharged more often from the emergency room. Spanish-speaking parents utilized the service less than English speakers. There were no disparities in utilization based on the insurance status or race. Conclusions. The after-hours service accurately triaged calls and reduced physician burden. Patients of all races and insurance statuses utilized the after-hours service equally well. Language was a barrier in the utilization.

Aim. To assess children’s subsequent device usage and caregiver attitudes to do-it-yourself real-time continuous glucose monitoring (DIY-rtCGM) at least 3 months after completing a randomized controlled trial (RCT). Methods. A brief online questionnaire or telephone call was used to collect the subsequent device usage and caregivers’ attitudes from a total of 55 families at least 3 months after their completion of an RCT investigating DIY-rtCGM adapted from their preexisting intermittently scanned glucose sensors plus education on using DIY-rtCGM system. To be eligible for the RCT, children had to be aged 2–13 years, have type 1 diabetes ≥6 months, and be rtCGM naïve. Data collected investigated current CGM use post-RCT and attitudes/user experiences to DIY-rtCGM in the months since RCT study support ended. Results. Overall, responses from 81.8% (45/55) of caregivers were received. Mean age of children was 9.0 ± 2.7 years, and 31 (68.9%) children used insulin pumps. After 3 months, 44.4% (20/45) of responding caregivers reported ongoing DIY-rtCGM use, and of these, only 13 used DIY-rtCGM as the primary glucose monitoring method 100% of time. Of the 25 (55.6%) families who ceased DIY-rtCGM, 40% (10/25) had transitioned to commercial rtCGM. More than half of families (60%, 12/20) who continued DIY-rtCGM use had a very or extremely positive attitude toward the technology and 75% (15/20) of these families planned to continue DIY-rtCGM use. However, signal loss and sensor inaccuracy remained the major reasons among all responders both for decreased DIY-rtCGM wear time and eventual cessation. Burden of use primarily related to technical errors that could not be solved, and alarms, both of which were reported to contribute to discontinuation. Conclusions. This study highlights that, among families voluntarily using DIY-rtCGM at least 3 months following support from a trial, more than half have ceased using DIY-rtCGM, with 40% of those discontinuing switching to commercial rtCGM. While overall perceptions of DIY-rtCGM remain largely positive, burdens of use are high and contribute to discontinuation.

Introduction. Despite heightened risk of cardiovascular disease (CVD) among individuals with type 1 diabetes, few studies in this population have investigated the development of CVD using early markers in adolescence. We compared risk factors (blood pressure (BP) and dyslipidemia) and early markers of CVD between adolescents with and without type 1 diabetes and explored effect modification by sex. Methods. Cross-sectional study using data from the CARdiovascular Disease risk in pEdiatric type 1 diAbetes (CARDEA) study. We recruited 100 adolescents with type 1 diabetes at the Sainte-Justine University Hospital Center and 97 adolescents without diabetes (14–18 years). We measured arterial stiffness by carotid-femoral pulse wave velocity, endothelial function by brachial artery flow-mediated dilation test, as well as left ventricular (LV) mass, papillary mass, and wall thickness by cardiac MRI. We used multivariable linear regression models to assess the impact of type 1 diabetes on each outcome adjusting for age, sex, ethnicity, adiposity, and familial income. Results. Adolescents with type 1 diabetes had 0.21 standard deviations (SD) (95% CI: 0.04; 0.38) higher diastolic blood pressure z-score (zDBP), 0.21 mmol/L (95% CI: 0.02; 0.40) higher low-density lipoprotein cholesterol (LDL-c) levels, and 17% (95% CI: 4; 29) higher triglyceride levels and lower endothelial function based on acceleration (−77.4 cm/s2, 95% CI: −133.1; −21.6) compared with adolescents without diabetes. Girls with type 1 diabetes had higher systolic blood pressure z-score (zSBP), and boys with type 1 diabetes had lower LV mass and wall thickness compared to healthy peers. Conclusions. In addition to higher BP and abnormal lipid profiles, adolescents with type 1 diabetes present endothelial dysfunction and alterations in cardiac structure (in boys) compared to adolescents without diabetes, suggesting that CVD prevention should be incorporated into type 1 diabetes management early in the disease.

Background. Depression is a common comorbidity in adolescents with type 1 diabetes (T1D). It is unclear if patterns of responses from questionnaires used to screen for depressive symptoms are influenced by the burden of living with T1D and/or the consequences of hyperglycemia. Based on this gap in the adolescent research, we sought to identify potential differences in depression screening response patterns between adolescents with and without T1D and relate response patterns with glycemic outcomes. Methods. Using a retrospective case–control design, we analyzed electronic health records for age, sex, and race-matched adolescents 13–18 years of age from a pediatric diabetes clinic (n = 477) and a pediatric primary care clinic (n = 477) in the United States. Adolescents in both settings were screened for depressive symptoms during the same time period using the Patient Health Questionnaire-9 (PHQ-9). Results. Participant demographics for matched characteristics were: 53.5% male, 71.7% White, median age 13.0 (interquartile range = 13.0, 14.0). After controlling for type of insurance, adolescents with T1D were more likely to have higher total PHQ-9 scores (odds ratio (OR) = 1.51, 95% CI = 1.17, 1.98, p = 0.002 ) and higher somatic subscores (OR = 1.57, 95% CI = 1.20, 2.05, p = 0.001 ) compared to the primary care sample. The pattern of item endorsement greater than “not at all” indicated that adolescents with T1D were more likely to have higher values for somatic items such as “trouble falling asleep” and “feeling tired” than those in the primary care sample. Item-total correlations and Cronbach’s α indicated that all items were contributing to the overall score in the same manner in each group. Conclusions. Symptom endorsement for sleep and fatigue were higher for adolescents with T1D and without T1D. Study results support the need for further examination of the origins of somatic symptoms in T1D and for an additional examination of the specificity of depression screening instruments used in routine pediatric diabetes care.

Introduction. Since there is no uniform global diabetes trend in childhood and adolescence, regional epidemiological surveys of diabetes incidences are important. In Austria, the incidences of type 1 diabetes (T1D), type 2 diabetes (T2D), and other forms of diabetes have been recorded for decades. Methods. To analyze recent developments of diabetes incidence within the decades long-standing Austrian nationwide prospective population-based incidence study for diabetes in children aged <15 years. We estimated time trends of age-standardized rates from 1989 to 2021 for T1D and T2D by joinpoint analysis. Annual percent changes (APCs) were calculated. Case ascertainment was 97%. Results. We observed an unusual increase of T1D incidence in the year 2021, reaching a peak of 28.7/100,000/PY (person years). From 2011 to 2020, there had been a constant plateau phase in the total cohort (APC 0.78, 95% CI [−0.99, 2.58], p=0.379), which had followed a steep increase of T1D incidence (APC 4.6, 95% CI [3.94, 5.19], p<0.001) from 1989 to 2011. Age-specific differences in T1D incidence development were observed. For the first time, we observed a statistically significant constant increase in T2D during the observation period (APC 3.47, 95% CI [0.76, 6.26], p=0.014). Other forms of diabetes are two times more common than T2D in this age group. Conclusion. The incidence of T1D in Austrian children <15 years is still increasing and showed a peak in 2021. For the first time, a significant increase in pediatric T2D was observed in Austria.

Background. Postacute sequelae of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (PASC) is associated with worsening diabetes trajectory. It is unknown whether PASC in children with type 1 diabetes (T1D) manifests as worsening diabetes trajectory. Objective. To explore the association between SARS-CoV-2 infection (COVID-19) and T1D-related healthcare utilization (for diabetic ketoacidosis (DKA) or severe hypoglycemia (SH)) or hemoglobin (Hb) A1c trajectory. Methods: We included children <21 years with T1D and ≥1 HbA1c prior to cohort entry, which was defined as COVID-19 (positive diagnostic test or diagnosis code for COVID-19, multisystem inflammatory syndrome in children, or PASC) or a randomly selected negative test for those who were negative throughout the study period (Broad Cohort). A subset with ≥1 HbA1c value from 28 to 275 days after cohort entry (Narrow Cohort) was included in the trajectory analysis. Propensity score-based matched cohort design followed by weighted Cox regression was used to evaluate the association of COVID-19 with healthcare utilization ≥28 days after cohort entry. Generalized estimating equation (GEE) models were used to measure change in HbA1c in the Narrow Cohort. Results. From March 01, 2020 to June 22, 2022, 2,404 and 1,221 youth met entry criteria for the Broad and Narrow Cohorts, respectively. The hazard ratio for utilization was (HR 1.45 (95% CI: 0.97, 2.16)). In the Narrow Cohort, the rate of change (slope) of HbA1c increased 91–180 days after cohort entry for those with COVID-19 (0.138 vs. −0.002, p = 0.172 ). Beyond 180 days, greater declines in HbA1c were observed in the positive cohort (−0.104 vs. 0.008 per month, p = 0.024 ). Conclusion. While a trend toward worse outcomes following COVID-19 in T1D patients was observed, these findings were not statistically significant. Continued clinical monitoring of youth with T1D following COVID-19 is warranted.

Background and Aims. The optimal basal and bolus insulin distribution in type 1 diabetes (T1D) is still controversial. Herein, we aimed to determine the variability of basal to total daily insulin dose according to treatment modality and diabetes technologies from the Better Control in Pediatric and Adolescent Diabetes: Working to Create Centers of Reference (SWEET) registry. Methods. The study cohort was generated by using the SWEET database. Patients with T1D for at least 2 years, aged between 2.5 and 18 years, with at least one clinic visit between June 2010 and June 2021, were included in the study. Four groups were composed according to treatment modality as follows: multiple daily injections (MDI) without continuous glucose monitoring (CGM); MDI with CGM; subcutaneous insulin infusion (CSII) without CGM; and CSII with CGM. Data of the participants were analyzed and compared for each treatment modality separately. Results. A total of 38,956 children and adolescents were included in the study. Of the study sample, 48.6% were female, the median (range) age was 15.2 (11.9–17.2) years, and the median diabetes duration was 6.0 (3.8–9.0) years. The distribution of treatment modality was as follows: MDI without CGM, 32.9%; MDI with CGM, 18.0%; CSII without CGM, 11.7%; and CSII with CGM, 37.3%. In unadjusted data, regardless of treatment modality, all the analyses revealed a significant association between basal dose to total daily insulin dose (BD/TDD) with male gender, younger age group, and lower HbA1c, which were all related to a decreased ratio of BD/TDD (all p < 0.05 ). There was no association between BD/TDD and different diabetes technologies after the age, gender, and diabetes duration were adjusted. Conclusions. Herein, we showed that there was an association between lower proportions of basal to total insulin and lower hemoglobin A1c in a large cross-sectional cohort of children who had T1D. There was also an association between lower BD/TDD and younger age. There was no significant difference between BD/TDD ratios under different diabetes technologies (CGM and/or CSII).