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Many adolescents may experience a deterioration in metabolic control—attributable to one or several of the following: endocrine changes leading to increased insulin resistance (B) erratic meal and exercise patterns (C) poor adherence to treatment regimens (C) eating disorders (C) hazardous and risk-taking behaviors (C/E) It is essential to develop appropriate communication skills to facilitate teaching and education, and recognize the need for privacy and confidentiality for this age group (E). In the context of type 1 diabetes, many adolescents may experience a deterioration in metabolic control often attributable to erratic meal and exercise patterns, poor adherence to treatment regimens, hazardous and risk-taking behaviors, disordered eating behaviors, other mental health issues, and endocrine changes associated with puberty, leading to greater insulin resistance. Understand that attending to the developmental needs of young people may be just as important for quality of life as diabetes-specific treatment. When there is conflict between the needs of diabetes management and the adolescent's social development and peer activities, a stepwise approach with interim achievable goals can be used to bridge competing priorities Providing well-directed education to help understand the physiological changes of puberty, their effect on insulin dose, difficulties of weight control and dietary regulation.

Early advances in diabetes treatment may have inadvertently increased the burden of diabetes care, which for some people may impair quality of life and psychosocial health. [...]a body of research has explored how the burdens of these technologies can be offset by the benefits they may provide, determining how to set realistic expectations for what assistance new therapies may provide, and informing the development of the next generation of technologies to minimize the burden they may cause. [...]diabetes technology presents an opportunity to improve glycemic control by lowering HbA1c, reducing hypoglycemia, and lowering the burden of care for T1D on children, adolescents, young adults, and their families. Since the 2014 ISPAD guidelines, numerous advances have been made in diabetes technology. [...]a very consistent picture has emerged in the literature supporting the use of pump therapy for youth with T1D, namely mean HbA1c decreased 0.2% to 1.1%, clinically important hypoglycemia was reduced, and no significant increase in body mass index (BMI) z-score was recorded.

OBJECTIVE: To test models of unidirectional and bidirectional change between treatment adherence and glycemic control in youth with type 1 diabetes. RESEARCH DESIGN AND METHODS: We conducted a 2-year longitudinal, multisite study of 225 youth with type 1 diabetes recruited at the cusp of adolescence (aged 9–11 years) to describe the mutual influences of glycemic control as measured by HbA1c and treatment adherence as measured by blood glucose monitoring frequency (BGMF) during the transition to adolescence. RESULTS: HbA1c increased from 8.2 to 8.6% (P < 0.001) and BGMF decreased from 4.9 to 4.5 checks per day (P < 0.02) during the 2-year period. Changes in the BGMF slope predicted changes in HbA1c. A change (increase) in HbA1c was associated with a change (decrease) in BGMF of 1.26 (P < 0.001) after controlling for covariates. CONCLUSIONS: The magnitude of the effect of declining treatment adherence (BGMF) on glycemic control in young adolescents may be even greater than declines observed among older adolescents. BGMF offers a powerful tool for targeted management of glycemic control for type 1 diabetes during the critical transition to adolescence.

Updated and Revised Diabetes Family Conflict Scale Korey K. Hood , PHD 1 , Deborah A. Butler , MSW 1 , Barbara J. Anderson , PHD 2 and Lori M.B. Laffel , MD, MPH 1 1 Pediatric, Adolescent, and Young Adult Section, Genetics and Epidemiology Section, Behavioral Research and Mental Health Section, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts 2 Children's Nutrition Research Center, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas Address correspondence and reprint requests to Lori Laffel, MD, MPH, Pediatric, Adolescent, and Young Adult Section, Joslin Diabetes Center, One Joslin Place, Boston, MA 02215. E-mail: lori.laffel{at}joslin.harvard.edu Abstract OBJECTIVE — The purpose of this study was to update the Diabetes Family Conflict Scale (DFCS) in the era of intensive diabetes management and provide an indication of its psychometric properties. RESEARCH DESIGN AND METHODS — The revised DFCS and measures of negative emotions around blood glucose monitoring (BGM), quality of life, and perceived parental burden from diabetes management were completed by 202 children and adolescents with type 1 diabetes and their primary caregivers. Insulin regimen, adherence, and glycemic control were also assessed. RESULTS — The revised DFCS demonstrated strong psychometric properties. There was acceptable internal consistency for child and caregiver forms of the DFCS. Factor analysis revealed two factors related to direct and indirect management tasks. Both child ( r = 0.27, P < 0.01) and caregiver ( r = 0.26, P < 0.01) DFCS scores were correlated with A1C values. Multivariate analysis of factors usually associated with A1C values showed an additive, independent contribution of diabetes-specific family conflict to the prediction of glycemic control: F (12,189) = 6.17, P < 0.01, R 2 = 0.28. Conflict around direct management tasks (e.g., BGM) was a more important predictor of higher A1C levels than conflict around indirect management tasks (e.g., telling friends about diabetes). CONCLUSIONS — The revised and updated DFCS demonstrates strong psychometric properties and can be used as a tool for measuring the level of diabetes-specific conflict in families with children and adolescents with type 1 diabetes. BGM, blood glucose monitoring BGMC, Blood Glucose Monitoring Communication DCCT, Diabetes Control and Complications Trial DFCS, Diabetes Family Conflict Scale PAID, Problem Areas in Diabetes PedsQL, Pediatric Quality of Life Inventory Footnotes Published ahead of print at http://care.diabetesjournals.org on 19 March 2007. DOI: 10.2337/dc06-2358. A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances. The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked “advertisement” in accordance with 18 U.S.C Section 1734 solely to indicate this fact. Accepted March 14, 2007. Received November 17, 2006. DIABETES CARE

What is this summary about? This is a plain language summary of a survey on experiences and views of (1) adults who were treated with teplizumab in early type 1 diabetes (T1D) and (2) caregivers of children who were treated with teplizumab in early T1D. Teplizumab is a treatment currently approved to delay the onset of stage 3 T1D in adults and children aged 8 years and older with stage 2 T1D. The survey collected information on: Characteristics and personal and family health history of the respondents. Experiences with finding out they or the child they care for had early T1D (screening and diagnosis). Thoughts and feelings before and after receiving treatment with teplizumab. Expectations for future health. This survey is the first to ask about the real-world experiences (outside of a clinical trial) of adults treated with teplizumab and caregivers of children treated with teplizumab. What were the results? Most people agreed with the statement that they were grateful for the chance to receive teplizumab (or for the child they care for to receive teplizumab). Most people also thought teplizumab would make their T1D easier to manage. Most people still worried about their condition getting worse and kept a close eye on their glucose levels after treatment with teplizumab. Even though they were concerned, they would recommend teplizumab to others and make the same decision for treatment if another family member had early T1D. What do the results of the survey mean? This survey captured the experiences and views of adults who received teplizumab or caregivers of children who received teplizumab. These findings are important for people who are considering screening for T1D or treatment with teplizumab, people who want to understand the possible consequences of having a screening test result showing early T1D, and clinicians who are considering teplizumab for their patients.

IntroductionProject ECHO (Extension for Community Healthcare Outcomes) is a tele-education outreach model that seeks to democratize specialty knowledge to reduce disparities and improve health outcomes. Limited utilization of endocrinologists forces many primary care providers (PCPs) to care for patients with type 1 diabetes (T1D) without specialty support. Accordingly, an ECHO T1D program was developed and piloted in Florida and California. Our goal was to demonstrate the feasibility of an ECHO program focused on T1D and improve PCPs’ abilities to manage patients with T1D.Research design and methodsHealth centers (ie, spokes) were recruited into the ECHO T1D pilot through an innovative approach, focusing on Federally Qualified Health Centers and through identification of high-need catchment areas using the Neighborhood Deprivation Index and provider geocoding. Participating spokes received weekly tele-education provided by the University of Florida and Stanford University hub specialty team through virtual ECHO clinics, real-time support with complex T1D medical decision-making, access to a diabetes support coach, and access to an online repository of diabetes care resources. Participating PCPs completed pre/post-tests assessing diabetes knowledge and confidence and an exit survey gleaning feedback about overall ECHO T1D program experiences.ResultsIn Florida, 12 spoke sites enrolled with 67 clinics serving >1000 patients with T1D. In California, 11 spoke sites enrolled with 37 clinics serving >900 patients with T1D. During the 6-month intervention, 27 tele-education clinics were offered and n=70 PCPs (22 from Florida, 48 from California) from participating spoke sites completed pre/post-test surveys assessing diabetes care knowledge and confidence in diabetes care. There was statistically significant improvement in diabetes knowledge (p≤0.01) as well as in diabetes confidence (p≤0.01).ConclusionsThe ECHO T1D pilot demonstrated proof of concept for a T1D-specific ECHO program and represents a viable model to reach medically underserved communities which do not use specialists.

In a multicenter, randomized, crossover trial involving children 1 to 7 years of age with type 1 diabetes, a closed-loop system was compared with sensor-augmented pump therapy in random order. The closed-loop system improved glycemic control in very young children with type 1 diabetes, without increasing the time spent in a hypoglycemic state.

IntroductionDiabetes disparities exist based on socioeconomic status, race, and ethnicity. The aim of this study is to compare two cohorts with diabetes from California and Florida to better elucidate how health outcomes are stratified within underserved communities according to state location, race, and ethnicity.Research design and methodsTwo cohorts were recruited for comparison from 20 Federally Qualified Health Centers as part of a larger ECHO Diabetes program. Participant-level data included surveys and HbA1c collection. Center-level data included Healthcare Effectiveness Data and Information Set metrics. Demographic characteristics were summarized overall and stratified by state (frequencies, percentages, means (95% CIs)). Generalized linear mixed models were used to compute and compare model-estimated rates and means.ResultsParticipant-level cohort: 582 adults with diabetes were recruited (33.0% type 1 diabetes (T1D), 67.0% type 2 diabetes (T2D)). Mean age was 51.1 years (95% CI 49.5, 52.6); 80.7% publicly insured or uninsured; 43.7% non-Hispanic white (NHW), 31.6% Hispanic, 7.9% non-Hispanic black (NHB) and 16.8% other. Center-level cohort: 32 796 adults with diabetes were represented (3.4% with T1D, 96.6% with T2D; 72.7% publicly insured or uninsured). Florida had higher rates of uninsured (p<0.0001), lower continuous glucose monitor (CGM) use (18.3% Florida; 35.9% California, p<0.0001), and pump use (10.2% Florida; 26.5% California, p<0.0001), and higher proportions of people with T1D/T2D>9% HbA1c (p<0.001). Risk was stratified within states with NHB participants having higher HbA1c (mean 9.5 (95% CI 8.9, 10.0) compared with NHW with a mean of 8.4 (95% CI 7.8, 9.0), p=0.0058), lower pump use (p=0.0426) and CGM use (p=0.0192). People who prefer to speak English were more likely to use a CGM (p=0.0386).ConclusionsCharacteristics of medically underserved communities with diabetes vary by state and by race and ethnicity. Florida’s lack of Medicaid expansion could be a factor in worsened risks for vulnerable communities with diabetes.

Abstract Context Early initiation of continuous glucose monitoring (CGM) is advocated for youth with type 1 diabetes (T1D). Data to guide CGM use on time-in-range (TIR), hypoglycemia, and the role of partial clinical remission (PCR) are limited. Objective Our aims were to assess whether 1) an association between increased TIR and hypoglycemia exists, and 2) how time in hypoglycemia varies by PCR status. Methods We analyzed 80 youth who were started on CGM shortly after T1D diagnosis and were followed for up to 1-year post diagnosis. TIR and hypoglycemia rates were determined by CGM data and retrospectively analyzed. PCR was defined as (visit glycated hemoglobin A1c) + (4*units/kg/day) less than 9. Results Youth were started on CGM 8.0 (interquartile range, 6.0-13.0) days post diagnosis. Time spent at less than 70 mg/dL remained low despite changes in TIR (highest TIR 74.6 ± 16.7%, 2.4 ± 2.4% hypoglycemia at 1 month post diagnosis; lowest TIR 61.3 ± 20.3%, 2.1 ± 2.7% hypoglycemia at 12 months post diagnosis). No events of severe hypoglycemia occurred. Hypoglycemia was rare and there was minimal difference for PCR vs non-PCR youth (54-70 mg/dL: 1.8% vs 1.2%, P = .04; < 54mg/dL: 0.3% vs 0.3%, P = .55). Approximately 50% of the time spent in hypoglycemia was in the 65 to 70 mg/dL range. Conclusion As TIR gradually decreased over 12 months post diagnosis, hypoglycemia was limited with no episodes of severe hypoglycemia. Hypoglycemia rates did not vary in a clinically meaningful manner by PCR status. With CGM being started earlier, consideration needs to be given to modifying CGM hypoglycemia education, including alarm settings. These data support a trial in the year post diagnosis to determine alarm thresholds for youth who wear CGM.