Before the discovery of insulin in 1922, treatment of diabetes was limited to palliative methods along with carbohydrate restriction. Bouchardat observed resolution of glycosuria with ...calorie-controlled diets as well as intermittent fasts. From 1914 to 1919, Dr. Frederick Allen placed patients on severely restricted caloric diets, and that approach was adopted to some extent by Dr. Elliott Joslin until the advent of insulin therapy. The biggest issue then was patient compliance, which continues to be important in diabetes management today. Here, a case study of a 14-year-old girl who was presented to a hospital for follow-up of type 1 diabetes after disagreement with her diabetes care provider regarding her choice of the ketogenic diet is offered. She was diagnosed with type 1 diabetes in Feb 2014, presenting with polyuria, polydipsia, and weight loss.
Background: Low calorie sweeteners (LCSs) are often used by youth with Type 1 Diabetes (T1D), as LCS can provide added sweetness to food and beverages at a reduced glycemic load. Whether LCS ...consumption is helpful or harmful for T1D management among youth is debated; however, little attention has been given to potential benefits of LCS consumption on psychosocial outcomes among youth with T1D. This is important because a diabetes diagnosis pervades all aspects of a child's life and LCS use may provide children with T1D with a sense of normalcy, potentially increasing their health-related quality of life (HRQOL).
Objective: To examine associations between LCS consumption and HRQOL among youth with T1D.
Methods: Sixty youth ages 11-17 with a diagnosis of T1D (Mage 12.9±1.8, 57.1% female, 70% Non-Hispanic White) and their parents (83.3% female, 71.6% Non-Hispanic White) were recruited from the Washington Nationals Diabetes Care Complex at Children's National Hospital (DCC) in Washington D.C. (N=20) and nationally using social media (N=40). Eligible youth and their parent attended a virtual study visit, where they provided demographic information, and completed a LCS consumption questionnaire (developed by the team for a previous study), along with the validated Type 1 Diabetes and Life measure (T1DAL). Means and frequencies were used to summarize the survey data, as appropriate, and associations between LCS intake and HRQOL were examined using multivariable linear regression, with adjustment for relevant covariates.
Results: Mean LCS consumption was 3.3±2.8 servings per day. No associations between LCS consumption (total, LCS beverage consumption, LCS food consumption) and HRQOL (total and subscales) were observed.
Conclusion: In our sample of youth with T1D, LCS intake was not associated with HRQOL. These results demonstrate that LCS use may not benefit psychosocial outcomes of youth with T1D, further reiterating the need to determine their metabolic and health effects in this high-risk patient population.
Disclosure
H.R.Moore: None. M.Fagundes grilo: None. N.Vallone: None. F.R.Cogen: None. R.Streisand: None. A.Sylvetsky: Consultant; Abbott.
Funding
Milken Institute School of Public Health
Abstract Introduction We examined changes in self-management behaviors after high school graduation in a cohort of emerging adults with type 1 diabetes. Methods Sixty-four emerging adults reported on ...diabetes self-management behaviors at three time points over a 1-year period. Glycemic control and blood glucose monitoring frequency data were collected from the medical chart. Results Collaboration with parents decreased, diabetes problem-solving and communication increased, and glycemic control worsened during the first year after high school ( p < .05). Problem solving appeared to be protective against worsening glycemic control; higher baseline diabetes problem solving significantly predicted better glycemic control at the 1-year follow-up. Discussion Emerging adults demonstrate increased independence in diabetes problem solving and communication with health care providers in the year after high school. Problem-solving skills may help emerging adults adapt type 1 diabetes self-care in response to unpredictable schedules after high-school, and promoting these skills may prevent deteriorations in glycemic control during this risky period.
Emerging adulthood is a transitional period for type 1 diabetes management, and aspects of family functioning such as family conflict and responsibility for diabetes management likely change ...following high school graduation. This study examined changes in diabetes-specific family conflict, family responsibility for diabetes management tasks, and associations with glycemic control up to 1 year after high school. Seventy-nine emerging adults with type 1 diabetes (M age = 18.09 ± .43 years; 51% female; 71% Caucasian) and their parents (73% female) completed self-report measures on diabetes-specific family conflict and family responsibility at 3 consecutive clinic visits, beginning in the spring of their senior year of high school. Hemoglobin A1c (HbA1c) was obtained from medical records. Diabetes-specific family conflict was relatively low; scores did not significantly change from baseline to Time 3. Parent responsibility for diabetes care decreased from baseline to Time 3. Higher parent- and emerging adult-reported family conflict and higher parent responsibility for diabetes care were associated with worse glycemic control (ps < .05). Parent-reported family conflict and the interaction between parent-reported family conflict and responsibility predicted HbA1c 1 year after high school. Conversely, HbA1c did not predict diabetes-specific family conflict or responsibility 1 year after high school. Findings indicate that diabetes-specific family conflict is associated with glycemic control after high school, even when emerging adults assume greater responsibility for diabetes self-care. Diabetes-specific family conflict levels were generally low and did not change over time despite this transitional period. If diabetes-specific conflict is present, it should be an important avenue for potential intervention for emerging adults with type 1 diabetes.
Low-calorie sweeteners (LCS) are commonly consumed by children with type 1 diabetes (T1D), yet their role in cardiometabolic health is unclear. This study examined the feasibility, acceptability, and ...preliminary effects of 12 weeks of LCS restriction among children with T1D. Children (n = 31) with T1D completed a two-week run-in (n = 28) and were randomly assigned to avoid LCS (LCS restriction, n = 15) or continue their usual LCS intake (n = 13). Feasibility was assessed using recruitment, retention, and adherence rates percentages. Acceptability was assessed through parents completing a qualitative interview (subset, n = 15) and a satisfaction survey at follow-up. Preliminary outcomes were between-group differences in change in average daily time-in-range (TIR) over 12 weeks (primary), and other measures of glycemic variability, lipids, inflammatory biomarkers, visceral adiposity, and dietary intake (secondary). Linear regression, unadjusted and adjusted for age, sex, race, and change in BMI, was used to compare mean changes in all outcomes between groups. LCS restriction was feasible and acceptable. No between-group differences in change in TIR or other measures of glycemic variability were observed. However, significant decreases in TNF-alpha (−0.23 ± 0.08 pg/mL) and improvements in cholesterol (−0.31 ± 0.18 mmol/L) and LDL (−0.60 ± 0.39 mmol/L) were observed with usual LCS intake, compared with LCS restriction. Those randomized to LCS restriction did not report increases in total or added sugar intake, and lower energy intake was reported in both groups (−190.8 ± 106.40 kcal LCS restriction, −245.3 ± 112.90 kcal usual LCS intake group). Decreases in percent energy from carbohydrates (−8.5 ± 2.61) and increases in percent energy from protein (3.2 ± 1.16) and fat (5.2 ± 2.02) were reported with usual LCS intake compared with LCS restriction. Twelve weeks of LCS restriction did not compromise glycemic variability or cardiometabolic outcomes in this small sample of youth with T1D. Further examination of LCS restriction among children with T1D is warranted.
Metformin is the first-line therapy for youth-onset type 2 diabetes mellitus (Y-T2D) but is suboptimal in up to 50% of youth. The reasons for increased failure rates are unknown. Metformin plasma ...concentration reflects total body distribution and kinetics but is not used clinically in adults because peak metformin concentration varies widely. Few studies, and none in youth, have measured trough therapeutic concentration as a potential biomarker of response. We hypothesized that trough metformin plasma concentrations after short-term therapy would be associated with treatment response. In this secondary analysis of a randomized trial of metformin alone vs. metformin and liraglutide (combo) therapy Y-T2D youth, we determined the relationship of metformin concentration with glycemia. Nineteen Y-T2D: age 15.4±2.1 (12-20y) mean±SD (range) , 61% female, Tanner Stage IV-V, BMI 40.0±8.0 (22.1-53.4 kg/m2) were randomized to 2000mg/day metformin (n=10) or 2000mg metformin+ 1.8mg liraglutide (combo, n=8) for 3 months after a 5-7 day drug-free run-in period. At baseline, youth on combo had higher HbA1c (7.1±0.7; 6.2±0.6%, P=0.006) but had similar BMI, fasting glucose, and 2hr glucose on OGTT. Metformin concentrations increased (combo:337±559 vs. metformin: 420±433 (1.6-1537 ng/mL) , P=0.7) and negatively correlated with change in 2hr glucose (combo: r=-0.9, P=0.002; metformin: r=-0.73, P=0.02) , fasting glucose (combo: r=-0.59, P=0.13; metformin: r=-0.64, P=0.06) , and change in HbA1c (combo: r=-0.89, P=0.01, metformin: r=0.31, P=0.4) . Metformin adherence measured by pill counts was 78% with no difference by group (combo: 80±20; metformin: 75±16%) . Metformin concentrations were not associated with percent adherence to medication or change in weight (P>0.10) . Overall, metformin concentrations were widely variable in Y-T2D but associated with improvements in glycemia after 3 months and should be explored as a viable biomarker for predicting treatment response in Y-T2D.
Disclosure
K.B. Dietsche: None. A. Zenno: None. S.A. Dixon: None. L. Mabundo: None. E.L. Shouppe: None. D.E. Estrada: None. F.R. Cogen: None. M. Walter: None. P. Walter: None. S.T. Chung: None.
Funding
NIDDK/NIH Intramural Research Program
Objective: Management of meals and mealtime behavior is often challenging for parents of young children with Type 1 diabetes. Parent functioning related to diabetes care may directly affect mealtime ...behaviors and glycemic control. This study evaluated associations among diabetes-specific parent functioning, parent and child mealtime behaviors, and glycemic control. Method: Parents of young children with Type 1 diabetes (n = 134) completed self-report measures assessing diabetes-specific functioning (hypoglycemia fear, diabetes self-efficacy, diabetes-related quality of life) and child and parent mealtime behaviors. Hemoglobin A1c and percentage of blood glucose values out of range (<70 mg/dL or >200 mg/dL) over a 30-day period were abstracted from medical charts as indicators of glycemic control. Structural equation modeling was utilized to evaluate predictors and related outcomes of child and parent mealtime behavior. Results: The proposed model fit the data very well. More frequent problematic child mealtime behaviors were associated with poorer glycemic control; however, more frequent problematic parent mealtime behaviors were marginally associated with better glycemic control. Poorer diabetes-specific parent functioning was associated with more frequent problematic child and parent mealtime behaviors. Conclusions: Problematic child mealtime behaviors, such as disruptive behavior, present a significant risk for poorer glycemic control. Parents may engage in ineffective mealtime management strategies in an effort to meet glycemic recommendations and avoid hyperglycemia and hypoglycemia. Future research will help to determine whether parents may benefit from specific, developmentally appropriate behavioral strategies to manage meals and snacks and promote optimal diabetes management.
Aims/hypothesis
Metformin is the only approved oral agent for youth with type 2 diabetes but its mechanism of action remains controversial. Recent data in adults suggest a primary role for the ...enteroinsular pathway, but there are no data in youth, in whom metformin efficacy is only ~50%. Our objectives were to compare incretin concentrations and rates of glucose production and gluconeogenesis in youth with type 2 diabetes before and after short-term metformin therapy compared with peers with normal glucose tolerance (NGT).
Methods
This is a case–control observational study in youth with type 2 diabetes who were not on metformin (
n
= 18) compared with youth with NGT (
n
= 10) who were evaluated with a 2 day protocol. A 75 g OGTT was administered to measure intact glucagon-like 1 peptide (iGLP-1), gastric inhibitory polypeptide (GIP) and peptide YY (PYY). Insulinogenic index (IGI) and whole-body insulin sensitivity were calculated using glucose and insulin levels from the OGTT. Basal rates of gluconeogenesis (
2
H
2
O), glucose production (6,6-
2
H
2
glucose) and whole-body lipolysis (
2
H
5
glycerol) were measured after an overnight fast on study day 2. Youth with type 2 diabetes (
n
= 9) were subsequently evaluated with an identical 2 day protocol after 3 months on the metformin study.
Results
Compared with individuals with NGT, those with type 2 diabetes had higher fasting (7.8 ± 2.5 vs 5.1 ± 0.3 mmol/l, mean ± SD
p
= 0.002) and 2 h glucose concentrations (13.8 ± 4.5 vs 5.9 ± 0.9 mmol/l,
p
= 0.001), higher rates of absolute gluconeogenesis (10.0 ± 1.7 vs 7.2 ± 1.1 μmol kg fat-free mass (FFM)
−1
min
−1
,
p
< 0.001) and whole-body lipolysis (5.2 ± 0.9 vs 4.0 ± 1.4 μmol kg
FFM
−1
min
−1
,
p
< 0.01), but lower fasting iGLP-1 concentrations (0.5 ± 0.5 vs 1.3 ± 0.7 pmol/l,
p
< 0.01). Metformin decreased 2 h glucose (pre metformin 11.4 ± 2.8 vs post metformin 9.9 ± 1.9 mmol/l,
p
= 0.04) and was associated with ~20–50% increase in IGI (median 25th–75th percentile pre 1.39 0.89–1.47 vs post 1.43 0.88–2.70,
p
= 0.04), fasting iGLP-1 (pre 0.3 ± 0.2 vs post 1.0 ± 0.7 pmol/l,
p
= 0.02), 2 h iGLP (pre 0.4 ± 0.2 vs post 1.2 ± 0.9 pmol/l,
p
= 0.06), fasting PYY (pre 6.3 ± 2.2 vs post 10.5 ± 4.3 pmol/l,
p
< 0.01) and 2 h PYY (pre 6.6 ± 2.9 vs post 9.0 ± 4.0 pmol/l,
p
< 0.01). There was no change in BMI, insulin sensitivity or GIP concentrations pre vs post metformin. There were no differences pre vs post metformin in rates of glucose production (15.0 ± 3.9 vs 14.9 ± 2.2 μmol kg
FFM
−1
min
−1
,
p
= 0.84), absolute gluconeogenesis (9.9 ± 1.8 vs 9.7 ± 1.7 μmol kg
FFM
−1
min
−1
,
p
= 0.76) or whole-body lipolysis (5.0 ± 0.7 vs 5.3 ± 1.3 μmol kg
FFM
−1
min
−1
,
p
= 0.20). Post metformin iGLP-1 and PYY concentrations in youth with type 2 diabetes were comparable to levels in youth with NGT.
Conclusions/interpretation
Overall, the improved postprandial blood glucose levels and increase in incretins observed in the absence of changes in insulin sensitivity and gluconeogenesis, support an enteroinsular mechanistic pathway in youth with type 2 diabetes treated with short-term metformin.
Graphical abstract
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