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Objective: This study sought to examine the reliability and validity of a novel pediatric type 1 diabetes knowledge assessment (KAT‐1) designed for children, adolescents, young adults and their parents/guardians. The instrument was designed to be integrated into the clinic workflow to obtain objective data electronically. Research Design and Methods: KAT‐1 was developed by a multidisciplinary team and includes 11 independent topical subscales. Forty children/caregivers participated in a pilot study; their feedback was used to improve item clarity and readability. Subsequently, a validation study was performed in 200 participants (100 children/adolescents/young adults with type 1 diabetes ages 11–21 years and 100 parents/guardians of children with type 1 diabetes ages 1–15 years) to examine correlations between the KAT‐1 scores and Revised Diabetes Knowledge Test (DKT2) scores and HbA1c. An item analysis was conducted to determine internal consistency and reliability; topical subscales were evaluated using Cronbach's alpha. Results: Total KAT‐1 scores were positively correlated with DKT2 scores r = 0.674, p < 0.001, and negatively correlated with HbA1c, r = −0.3, p < 0.001. All KAT‐1 subscales were positively and significantly correlated with one another and with total KAT‐1 score. Internal consistency of total KAT‐1 score was strong (Cronbach's α = 0.938, mean score 84.6, SD = 16.1) and 9 of 11 independent topical subscales demonstrated strong internal consistency. Completion time for subscales was <5 min. Conclusions: KAT‐1 is a valid instrument to assess type 1 diabetes knowledge. The instrument's short topical subscales can be used to objectively assess specific knowledge and individualize diabetes education. KAT‐1 has been integrated into our electronic health record (EPIC) and is available online at no cost. [ABSTRACT FROM AUTHOR]

Objective: There is a rise in overweight and obesity among children and adolescents with type 1 diabetes (T1D) in parallel with the rise in the metabolic syndrome (MetS) among children and adolescents. The aim of the study was to describe the prevalence and characteristics of MetS in children and adolescents with T1D compared to their healthy counterparts. Research Design and Methods: The study includes two Danish cohorts; (i) the Copenhagen cross sectional cohort 2016 of 277 children and adolescents with T1D that attend the pediatric outpatient clinic at a large hospital in greater Copenhagen and (ii) the CHAMPS‐study DK which is a population‐based cohort study of Danish children and adolescents (control cohort). Participants were categorized to have MetS if at least two of the following criteria were met: (i) systolic and/or diastolic blood pressure ≥ 90th percentile, (ii) waist circumference ≥90th percentile, and (iii) triglyceride ≥90th percentile and/or HDL ≤10th percentile. Results: The prevalence of children with Mets in the T1D cohort was higher than in the control cohort (p = 0.002). Moreover, participants with T1D had MetS at a lower level of BMI (p < 0.001) and waist circumference (p < 0.001) than participants with MetS from the control cohort (z‐scores = 0.90 and 1.51). Participants with MetS were younger than the other T1D participants (median 12.8 [9.9,14.8] vs. median 14.6 [11.2,16.9] years, p = 0.006). Conclusions: Children and adolescents with T1D have an increased risk of MetS compared to healthy controls and clinicians and caretakers should consider early prevention and health promotion strategies. [ABSTRACT FROM AUTHOR]

Objective: To assess the relationship between mindfulness and glycemia among adolescents with type 1 diabetes (T1D) with suboptimal glycemia, and evaluate the potential mediation by ingestive behaviors, including disordered eating, and impulsivity. Research Design and Methods: We used linear mixed models for hemoglobin A1c (HbA1c) and linear regression for continuous glucose monitoring (CGM) to study the relationship of mindfulness [Child and Adolescent Mindfulness Measure (CAMM)] and glycemia in adolescents with T1D from the 18‐month Flexible Lifestyles Empowering Change (FLEX) trial. We tested for mediation of the mindfulness‐glycemia relationship by ingestive behaviors, including disordered eating (Diabetes Eating Problem Survey—Revised), restrained eating, and emotional eating (Dutch Eating Behavior Questionnaire); and impulsivity (total, attentional, and motor, Barrett Impulsiveness Scale). Results: At baseline, participants (n = 152) had a mean age of 14.9 ± 1.1 years and HbA1c of 9.4 ± 1.2% [79 ± 13 mmol/mol]. The majority of adolescents were non‐Hispanic white (83.6%), 50.7% were female, and 73.0% used insulin pumps. From adjusted mixed models, a 5‐point increase in mindfulness scores was associated with a −0.19% (95%CI −0.29, −0.08, p = 0.0006) reduction in HbA1c. We did not find statistically significant associations between mindfulness and CGM metrics. Mediation of the relationship between mindfulness and HbA1c by ingestive behaviors and impulsivity was not found to be statistically significant. Conclusions: Among adolescents with T1D and suboptimal glycemia, increased mindfulness was associated with lower HbA1c levels. Future studies may consider mindfulness‐based interventions as a component of treatment for improving glycemia among adolescents with T1D, though more data are needed to assess feasibility and efficacy. [ABSTRACT FROM AUTHOR]

Background and objectiveMatrix metalloproteinases (MMPs) mediate blood-brain barrier dysfunction in inflammatory disease states. Our objective was to compare circulating MMPs in children with diabetic ketoacidosis (DKA) to children with type 1 diabetes mellitus without DKA.Research design and methodsThis was a prospective study performed at five tertiary-care pediatric hospitals. We measured plasma MMP-2, MMP-3, and MMP-9 early during DKA (time 1; within 2 h of beginning intravenous fluids) and during therapy (time 2; median 8 h; range: 4-16 h). The primary outcome was MMP levels in 34 children with DKA vs. 23 children with type 1 diabetes without DKA. Secondary outcomes included correlations between MMPs and measures of DKA severity.ResultsIn children with DKA compared with diabetes controls, circulating MMP-2 levels were lower (mean 77 vs. 244 ng/mL, p

Objective: To describe the epidemiology of pediatric type 1 diabetes over 50 years in Canterbury, New Zealand. Further, to explore variation in case presentation according to age, gender, ethnicity, urban/rural character, socio‐economic deprivation and immunogenetic features. Research Design and Methods: Prospective ascertainment of cases commenced in 1982, and incident cases presenting 1970–1982 were ascertained retrospectively from clinical records. Eligibility criteria included diagnosis of type 1 diabetes by a physician and commencement of insulin therapy at diagnosis and age less than 15 years. Data collection included name, hospital number, date of birth, date of diagnosis, and date of initiation of insulin treatment. Full address at diagnosis was assigned an urban–rural classification, and a deprivation score. HLA‐DQ susceptibility alleles and diabetes associated autoantibodies were determined. Results: The incidence of type 1 diabetes increased more than 5‐fold (3.9% per annum) over 50 years for the entire cohort. The mean for 5‐year periods, starting from 1970, increased from 5.3 to 29.0 cases per 100,000 person years. Incidence was greatest in the 10–14 year age group. The cohort is predominantly European (89.4%), but there has been an increase in cases identifying as New Zealand Māori in the last three decades. Weak evidence was found for reduced incidence of type 1 diabetes in rural regions (adjusted IRR = 0.70, 95%CI 0.52 to 0.91, p = 0.011). Conclusions: The incidence of type 1 diabetes in children aged less than 15 years continues to increase with time. Incidence was significantly affected by age, ethnicity, and urban/rural characterization of address at diagnosis. [ABSTRACT FROM AUTHOR]

Objective: The prevalence of depression among adolescents with type 1 diabetes is estimated to be 2--3 times higher than in the general population. In adults with type 1 diabetes and depression, short-term outcomes are worse compared to individuals just diagnosed with type 1 diabetes. This study aims to determine if depressive symptom endorsement is associated with glycemic outcomes and short-term complications in adolescents with type 1 diabetes. Research Design and Methods: Analysis was conducted using electronic medical records from the T1D Exchange Quality Improvement Collaborative. Adolescents with type 1 diabetes, aged 12--18, receiving treatment in a diabetes clinic who had been screened for depression with the PHQ-9 between 2016 and 2018 were eligible for inclusion. Individuals must have also had HbA1c data available from the day of depression screening and from 10 to 24 weeks after screening; the final sample size was 1714. Results: Almost 30% of adolescents endorsed mild or greater (PHQ-9 ≥ 5) depressive symptoms. Endorsement of mild or greater depressive symptoms was associated with an 18% increased risk of an HbA1c ≥7.5% and a 42% increased risk of an HbA1c ≥9.0% on the day of screener administration. Depressive symptom endorsement was also associated with an 82% increased risk for DKA. Conclusions: This study suggests that depression symptoms are associated with an increased risk for elevated HbA1c and short-term complications. With the rising incidence of type 1 diabetes in youth, routine screening, and appropriate management of depression is needed. [ABSTRACT FROM AUTHOR]

Objective: To assess whether introduction of continuous glucose monitoring (CGM) at diagnosis of type 1 diabetes (T1D), leads to greater uptake and continuation at 12 and 24 months, in a population‐based pediatric diabetes clinic. Research Design and Methods: All T1D children and adolescents diagnosed in the 12 months following full government subsidization of CGM were offered CGM from diagnosis at Women's and Children's Hospital, SA (Cohort 1). Uptake and continuation of CGM was compared to those diagnosed in the preceding year, who were started on CGM after diagnosis, but otherwise had identical diabetes management (Cohort 2). Demographic and clinical data were collected prospectively. The primary outcome variable was CGM wear >75% of the time at 12 and 24 months. Results: In Cohort 1, 84% were started on CGM at diagnosis. 88% had commenced CGM by 12 months and 90% by 24 months. In Cohort 2, CGM was started on average 10 months after diagnosis (range 1–25 months), with 81% started on CGM within 24 months of subsidization. At 24 months, 78% of Cohort 1 and 66% of Cohort 2 were wearing CGM >75% of the time (p = 0.26), higher than the WCH Clinic as a whole (58%). There was no difference in HbA1c between cohorts. Conclusion: Starting CGM at diagnosis of T1D is feasible and well received by families, with high uptake across all ages. Although CGM continuation (wearing CGM >75% of the time) was slightly higher in Cohort 1 than Cohort 2, this did not reach statistical significance. [ABSTRACT FROM AUTHOR]

Objective: To assess current practice patterns and identify knowledge gaps among pediatric endocrinologists in the United States regarding screening and counseling for combustible tobacco and e‐cigarette use in youth with diabetes. Introduction: Electronic cigarettes (e‐cigarettes) are the most used tobacco product among adolescents and may be associated with an increased risk of progression to combustible cigarette smoking, cardiovascular disease, and stroke. Diabetes mellitus is a known risk factor for cardiovascular disease, and nicotine products can increase this risk. We sought to assess current practice patterns and identify knowledge gaps among pediatric endocrinologists in the United States regarding screening and counseling for combustible tobacco and e‐cigarette use in youth with diabetes. Research Design and Methods: We conducted an anonymous, online‐based survey of Pediatric Endocrine Society members who provide care to youth with Type 1 or Type 2 diabetes. The survey collected information about provider demographics and smoking habits, knowledge and attitudes regarding screening and counseling for combustible tobacco and e‐cigarette use, and current practice patterns. Results: The survey was completed by 106 individuals of whom 64 reported providing care to youth with diabetes mellitus and ever asking about combustible tobacco or e‐cigarette use. The majority of respondents were female, attending providers, and working in academic medical centers. None reported a history of formal training in e‐cigarette counseling but recognized the harms of e‐cigarette use. Nearly all (98%) who ever screen for nicotine use reported routinely screening for combustible tobacco use, while 18% never screen for e‐cigarette use (p < 0.01). Over 80% of respondents reported feeling confident or very confident about discussing the harms of combustible tobacco, compared to 58% reporting the same confidence in discussing harms of e‐cigarette use (p < 0.0001). Over 90% of respondents agreed that pediatric endocrinology providers should ask about nicotine use with over half agreeing that counseling reduces the risk of initiating nicotine product use, and 30% reported lack of change with counseling as a barrier to discussing nicotine use. Lack of visit time was the most reported barrier to discussing nicotine use. More providers cited lack of knowledge regarding e‐cigarettes compared to combustible tobacco as a barrier to discussing its use. Conclusions: Pediatric endocrinology providers recognize the harms of e‐cigarette use, but more frequently ask about combustible tobacco use compared to e‐cigarette use. This may be related to lower reported confidence and provider knowledge in counseling about e‐cigarette use. Increased utilization of existing resources and expanding opportunities for providers to learn more about e‐cigarettes may increase provider confidence and comfort in screening and counseling. [ABSTRACT FROM AUTHOR]

Objective: In patients treated for DKA, decrease the rate of visits experiencing one or more BG < 80 mg/dl by 10% within 24 months. Research Design and Methods: Plan‐do‐study‐act cycles tested interventions linked to key drivers including: standardized DKA guidelines incorporating a two‐bag fluid system, efficient ordering process, and care team education. Inclusion criterion: treatment for DKA with a bicarbonate value (HCO3) <15 mEq/L. Primary outcome: the percent of patient visits experiencing a BG < 80 mg/dl while undergoing treatment for DKA. Process measures included: order panel and order set utilization rates. Balancing measures included: emergency department and hospital lengths of stay, time to acidosis resolution (time to HCO3 ≥ 17 mEq/L), and admission rates. Outcomes were analyzed using statistical process control charts. Results: From January 2017 through May 2021, our institution treated 288 different patients during 557 visits for suspected DKA. Following our interventions, the overall percent of patient visits for DKA with a BG < 80 mg/dl improved from 32% to 5%. The team did see small improvements in emergency department and hospital lengths of stay; otherwise, there was no significant change in our balancing measures. Conclusions: Use of quality improvement methodology and standardized DKA management resulted in a significant reduction of BG < 80 mg/dl in patients treated for DKA. [ABSTRACT FROM AUTHOR]

Background: Adolescents and emerging adults with chronic health conditions such as type 1 diabetes mellitus (T1D) are more likely to engage in high‐risk behaviors. Previous studies regarding substance use in adolescents and emerging adults with T1D are mostly derived from cross‐sectional studies utilizing self‐administered questionnaires and are limited by lack of population‐based comparison groups. In addition, despite the rising popularity of vaping, little is known about the incidence of vaping in adolescents and emerging adults with T1D. Methods: We explored the incidence and prospective risk of substance use disorders (SUD) and vaping in adolescents and emerging adults with T1D compared to age and gender matched nondiabetic referents residing in Olmsted County, Rochester, MN. Results: Risk of incident SUD was higher in those with T1D compared to matched referents with alcohol, marijuana, and smoked tobacco being most common substances. When stratified by gender, these differences remained significant in males, but not females. Conclusions: While further work is needed to delineate the causative relationships between T1D, mental health, and substance abuse, our findings confirm the critical need for substance use screening and mental health support for adolescents and emerging adults with T1D. [ABSTRACT FROM AUTHOR]

Background: Type 1 diabetes mellitus (DM1), a chronic metabolic disorder of autoimmune origin, has been associated with oxidative stress (OS), which plays a central role in the onset, progression, and long‐term complications of DM1. The markers of OS lipid peroxidation products, lipid hydroperoxides (LOOH), and also malondialdehyde (MDA) and thiobarbituric reactive substances (TBARS) that oxidatively modify proteins (Pr) (i.e., PrMDA and PrTBARS, respectively), have been associated with DM2, DM1, diabetic neuropathy, and microalbuminuria. Objective/Subjects: Here, we investigated LOOH, PrMDA and PrTBARS in 50 children and adolescents with DM1 and 21 controls. Results: The novel OS marker PrTBARS was assessed for the first time in children and adolescents with DM1. LOOH and the pair PrMDA/PrTBARS, representing early and late peroxidation stages, respectively, are found to be significantly higher (130%, 50/90%, respectively, at p < 0.001) in patients with DM1 compared to controls. The studied OS parameters did not differ with age, age at diagnosis, sex, duration of DM1, presence of recent ketosis/ketoacidosis, or mode of treatment. Conclusions: We propose that LOOH, PrMDA and the new marker PrTBARS could serve as potential diagnostic clinical markers for identifying OS in children and adolescents with DM1, and may, perhaps, hold promise as a prognostic tool for future complications associated with the disease. [ABSTRACT FROM AUTHOR]

Background: Studies in animal models and humans with type 1 diabetes mellitus (T1DM) have shown that probiotic supplementation leads to decreased pro‐inflammatory cytokines (responsible for damaging β‐cells of the pancreas), improved gut barrier function, and induction of immune tolerance. Objective: To study the effect of supplementation of probiotics in children with T1DM on glycemic control, insulin dose, and plasma C‐peptide levels. Methods: A single‐centered, double‐blinded, and randomized placebo‐controlled pilot trial was conducted in children (2–12 years) with new‐onset T1DM. Ninety‐six children were randomized and allocated to Placebo or Intervention groups. The intervention included high dose (112.5 billion viable lyophilized bacteria per capsule) multi‐strain probiotic De Simone formulation (manufactured by Danisco‐Dupont) sold as Visbiome® in India. The probiotic was supplemented for 3 months and HbA1c, fasting C‐peptide, blood sugar records, and insulin dose was recorded at baseline and 3 months. Results: A total of 90 patients (45 in each group) were analyzed for outcome parameters. We found a significant decrease in HbA1c (5.1 vs. 3.8; p = 0.021) and a significant decline in total and bolus insulin dose (U/kg/day; p = 0.037 and 0.018, respectively) in the intervention group when compared with the placebo group. A significantly higher (p = 0.023) number of children achieved remission in the treatment group. We did not notice adverse effects in either of the study groups. Conclusion: Children with newly diagnosed T1DM managed with standard treatment along with probiotics showed better glycemic control and a decrease in insulin requirements; however, more extensive studies are further warranted. [ABSTRACT FROM AUTHOR]

Objective: To determine the incidence of new onset type 1 diabetes in children aged 0–14 years from 1977 to 2019 in Auckland, New Zealand. Research design and methods: A cohort study of children with type 1 diabetes aged 0–14 years (n = 1688; 50.4% male) managed by the regional diabetes service between 1977 and 2019. Incidence rates were estimated using census data. Results: The incidence of type 1 diabetes increased by 2.9%/year from 1977 to 2006 (95% confidence interval [CI] 2.13% – 3.48%). Although there was no significant change from 2006 to 2019 (−0.3%/year, 95% CI ‐1.62% – 1.08%), there was a dramatic fall from 1976 to 2018 in the proportion of New Zealand Europeans, from 69.9 to 33.9%. New Zealand Europeans had the highest incidence (23.3/100,000, 95% CI 20.6–26.1) compared to Māori (8.3/100,000, 95% CI 6.3–10.2), Pasifika (8.6/100,000, 95% CI 6.9–10.4) and other (6.4/100,000, 95% CI 4.7–8.0). All groups showed an overall increase in incidence over time, Māori 4.4%/year, Pasifika 3.7%, compared to New Zealand European 2.7%, and other 2.1%. Incidence increased consistently in 5–9 and 10–14 year olds (2.0% and 2.2%/year, respectively). By contrast, whereas 0–4 year olds showed an increase of 4.6%/year from 1977 to 2003 (p < 0.01), there was no change from 2003 to 2019 (p = 0.2). Conclusion: There has been a plateau in the incidence of type 1 diabetes in children 0–4 years of age in the Auckland region since 2003, but not older children. The apparent plateau in the overall incidence of new onset type 1 diabetes in children 0–14 years since 2006 was mediated by substantial changes in the ethnic makeup of the Auckland region. [ABSTRACT FROM AUTHOR]

Introduction: Disadvantaged and minority youth with type 1 diabetes are less likely to be on insulin pump therapy compared to the majority population. Little is known about how pediatric endocrinology providers determine eligibility for insulin pump. We aimed to identify provider factors influencing the decision to initiate insulin pump therapy. Methods: We conducted a survey of Pediatric Endocrine Society members who prescribe insulin pump therapy to pediatric patients with type 1 diabetes. The survey collected information about prescriber characteristics, use and adherence to guidelines, eligibility criteria, and objective and subjective factors that influence insulin pump prescription. Results: The survey was completed by 192 individuals who met eligibility criteria (14.1% response rate). The majority of respondents were attending providers, and were white, non‐Hispanic females. A minority of providers (22%) reported following written insulin pump guidelines, and many (70%) reported using personal guidelines to guide patient selection. Most providers had no objective eligibility criteria, aside from standard glucose monitoring. Providers identified patient lifestyle and increased risk of hypoglycemia, as well as patient and family factors such as motivation, realistic expectations of insulin pump use, ability to demonstrate carbohydrate counting, patient request, and ability to communicate as important in the decision to initiate insulin pump. Conclusion: Pediatric endocrinology providers place significant importance on subjective factors and utilize few objective criteria in determining eligibility for insulin pump. In the setting of the known disparities in insulin pump use, providers should utilize objective, consistent criteria to determine which patients are safe to initiate insulin pump. [ABSTRACT FROM AUTHOR]

Objective: We examined parental diabetes monitoring behaviors in a cohort of children at increased genetic risk for type 1 diabetes. We hypothesized that being informed of a positive islet autoantibody (IA) would increase monitoring behaviors. Research Design and Methods: The Environmental Determinants of Diabetes in the Young (TEDDY) study follows 8676 children with high‐risk human leucocyte antigen‐DQ genotypes from birth to age 15, including general population (GP) children and those with a first‐degree relative (FDR) with diabetes. Data on parental monitoring behaviors were solicited yearly. Serum samples were tested for IA and parents were informed of child results. We examined parental monitoring behaviors during the first 7 years of TEDDY. Results: In IA– children, the most common monitoring behavior was participating in TEDDY study tasks; up to 49.8% and 44.2% of mothers and fathers, respectively, reported this. Among FDRs, 7%–10% reported watching for diabetes symptoms and 7%–9% reported monitoring the child's glucose, for mothers and fathers, respectively. After IA+ notification, all monitoring behaviors significantly increased in GP parents; only glucose monitoring increased in FDR parents and these behaviors continued for up to 4 years. FDR status, accurate diabetes risk perception, and anxiety were associated with glucose monitoring in IA+ and IA– cohorts. Conclusions: Many parents view TEDDY participation as a way to monitor for type 1 diabetes, a benefit of enrollment in a longitudinal study with no prevention offered. IA+ notification increases short‐ and long‐term monitoring behaviors. For IA– and IA+ children, FDR parents engage in glucose monitoring, even when not instructed to do so. [ABSTRACT FROM AUTHOR]

Background: Type 1 diabetes (T1D) may coexist with primary immunodeficiencies, indicating a shared genetic background. Objective: To evaluate the prevalence and clinical characteristics of immunoglobulin deficiency (IgD) among children with T1D. Methods: Serum samples and medical history questionnaires were obtained during routine visits from T1D patients aged 4–18 years. IgG, IgA, IgM, and IgE were measured by nephelometry and enzyme‐linked immunosorbent assay (ELISA). IgG and IgM deficiency (IgGD, IgMD) were defined as IgG/IgM >2 standard deviations (SD) below age‐adjusted mean. IgE deficiency was defined as IgE <2 kIU/L. IgA deficiency (IgAD) was defined as IgA >2 SD below age‐adjusted mean irrespective of other immunoglobulin classes (absolute if <0.07 g/L, partial otherwise) and as selective IgAD when IgA >2 SD below age‐adjusted mean with normal IgG and IgM (absolute if <0.07 g/L, partial otherwise). Results: Among 395 patients (53.4% boys) with the median age of 11.2 (8.4–13.7) and diabetes duration 3.6 (1.1–6.0) years, 90 (22.8%) were found to have hypogammaglobulinemia. The IgGD and IgAD were the most common each in 40/395 (10.1%). Complex IgD was found in seven patients. Increased odds of infection‐related hospitalization (compared to children without any IgD) was related to having any kind of IgD and IgAD; OR (95%CI) = 2.1 (1.2–3.7) and 3.7 (1.8–7.5), respectively. Furthermore, IgAD was associated with having a first‐degree relative with T1D OR (95%CI) = 3.3 (1.4–7.6) and suffering from non‐autoimmune comorbidities 3.3 (1.4–7.6), especially neurological disorders 3.5 (1.2–10.5). Conclusions: IgDs frequently coexist with T1D and may be associated with several autoimmune and nonimmune related disorders suggesting their common genetic background. [ABSTRACT FROM AUTHOR]

Objective: To determine the effects of recreational football combined with caloric control on glycemia and cardiovascular health of adolescent boys with type 1 diabetes. Background: Though 12 weeks of physical activity alone improves the health of people with type 1 diabetes, there is little evidence that physical activity alone can improve glycemia in 12 weeks. Research Design and Methods: The participants were divided into four groups as follows: football with diet, football‐only, diet‐only, and the control groups. Each group consisted of 10 participants. The football with diet and the football‐only groups had 1.5 h of football twice a week for 12 weeks. The following outcomes were measured before and after 12 weeks: Glycated hemoglobin, fasting blood glucose, total cholesterol, high‐density lipoprotein, low‐density lipoprotein, triglycerides, and resting blood pressures. Changes were considered significant when p ≤ 0.050 and common language effect size ≤42% or common language effect size ≥58%. Results: Glycated hemoglobin decreased in the football with diet group (mean change (standard deviation) = −0.9 (1.0) %, p = 0.019, and common language effect size = 31.5%) and was different from the control group (p = 2.4 × 10−4 and common language effect size = 95.5%.). However, none of the intervention groups showed a clear change in blood lipids nor blood pressure. Conclusions: 12 weeks of combined football with diet intervention provides the greatest improvement in glycemia in adolescent boys with type 1 diabetes. [ABSTRACT FROM AUTHOR]

Background: Data regarding glycemic control in children and adolescents with a dual diagnosis of type 1 diabetes mellitus (T1DM) and attention‐deficit/hyperactivity disorder (ADHD) are limited. Objective: To compare various aspects of diabetes control among youth with T1DM, between those with and without ADHD. Methods: In this cross‐sectional study of youth with T1DM, 39 had ADHD (mean age 14.1 ± 2.8 years) and 82 did not (control group, mean age 12.6 ± 3.3 years). Health‐related quality of life was assessed by a Diabetes Quality of Life (DQOL) questionnaire submitted to their parents. Glycemic data were downloaded from glucometers, pumps, and continuous glucose monitoring systems. HbA1c levels, hospitalizations, and severe hypoglycemic and diabetes ketoacidosis events were retrieved from the medical files. Results: Compared to the control group mean HbA1c level of the ADHD group was higher: 8.3 ± 1.1% versus 7.7 ± 1.0% (p = 0.005) and the percent of time that glucose level was in the target range (70–180 mg/dl) was lower: 48 ± 17% versus 59 ± 14% (p = 0.006). Mean glucose and glucose variability were higher in the ADHD group. Youth with ADHD who were not pharmacologically treated had worse HbA1c and more hospitalizations than those who were treated. DQOL did not differ between the control group, the treated ADHD group, and the untreated ADHD‐Group. Conclusions: Dual diagnosis of T1DM and ADHD during childhood leads to worse diabetes control, which is more pronounced in the context of untreated ADHD. Healthcare providers should be aware of the difficulties facing youth with T1DM and ADHD in coping with the current intensive treatment of diabetes. [ABSTRACT FROM AUTHOR]

ObjectivesOptimizing glycemic control in pediatric type 1 diabetes (T1D) is essential to minimizing long-term risk of complications. We used the T1D Exchange database from 58 US diabetes clinics to identify differences in diabetes management characteristics among children categorized as having excellent vs. poor glycemic control.MethodsAmong registry participants 6-17 yr old with diabetes duration ≥ 2 yr, those with excellent control [(A1c

Objectives: Low‐carbohydrate and ketogenic diets are becoming increasingly popular choices for people with type 1 diabetes (T1D) aiming to achieve optimal glycemic control. A carbohydrate‐restricted diet in children has been associated with negative health effects including poor linear growth and inadequate bone mineralization. Guidelines for monitoring children and adolescents choosing to follow a carbohydrate‐restricted diet do not exist. We aimed to create a clinical protocol outlining how to clinically and biochemically follow patients choosing a carbohydrate‐restricted diet with the goal of medical safety. Methods: An interdisciplinary committee was formed and reviewed current consensus guidelines for pediatric patients on carbohydrate‐restricted diets for epilepsy and metabolic disorders. A literature search was done to determine management strategies for children with T1D on a low‐carbohydrate or ketogenic diet. Key health parameters that require monitoring were identified: growth, glycemic control, bone health, cardiometabolic health, and nutritional status. These health outcomes were used to develop a protocol for monitoring children on carbohydrate‐restricted diets. Results: A one‐page protocol for medical providers and educational materials for families interested in following a low‐carbohydrate or ketogenic diet were developed and successfully implemented into clinical care. Conclusion: Implementing a protocol for children on carbohydrate‐restricted diets in clinic allows medical providers to ensure medical safety while being open to discussing a family's dietary preferences. Following children in the protocol over time will lead to informed clinical guidelines for patients with T1D who choose to follow a carbohydrate‐restricted diet. [ABSTRACT FROM AUTHOR]

Background: Brown adipose tissue (BAT) is essential to maintain body temperature. Its ability to convert chemical energy in glucose and free fatty acids to heat is conferred by a unique protein, UCP‐1. BAT activity is greatest in children and adolescents, declining through adulthood. Blood glucose concentrations outside the normal nondiabetic range are common in type 1 diabetes and hyperglycaemia leads to insulin resistance in muscle and white adipose tissue, but whether this applies to BAT, is not known. Method: To investigate the effect of type 1 diabetes on BAT activity, we measured the supraclavicular temperature of 20 children with type 1 diabetes and compared them to 20 age‐matched controls, using infrared thermography. Results: The diabetes group had lower stimulated supraclavicular temperatures (diabetes group: 35.03 (34.76–35.30)°C; control group: 35.42 (35.16–35.69)°C; p = 0.037) and a reduced response in relative temperature following cold stimulation, after adjusting for BMI (diabetes group: 0.11 (0.03–0.18)°C; control group: 0.22 (0.15–0.29)°C; p = 0.034). In the diabetes group, there was no association between glycaemic measures and supraclavicular temperatures, but the method of insulin delivery may significantly affect the change in supraclavicular temperature with stimulation (injections: 0.01 (−0.07–0.09)°C; pump: 0.15 (0.04–0.26)°C; p = 0.028). Conclusions: While further work is needed to better understand the glucose‐insulin‐BAT relationship, one possible explanation for the reduced supraclavicular temperature is that exogenous, unlike endogenous, insulin, is not suppressed by the activity of the sympathetic nervous system, preventing lipolysis‐driven activation of BAT. [ABSTRACT FROM AUTHOR]

Background: To study the health‐related quality of life (HRQoL) in pediatric onset Type 1 diabetes mellitus (TIDM) in the state of Kerala in India. Methods: Diabetes specific HRQoL was determined in 107 subjects with onset of T1DM less than 21 years using the Pediatric Quality of Life Inventory (PedsQL) 3.2 questionnaire of which 69 also completed the PedsQL 4.0 generic questionnaire. The parents of these patients completed the proxy scoring questionnaire. The generic HRQoL of T1DM was compared with control population without diabetes. Results: Mean age of onset of T1DM was 8.2 ± 4.6 years and mean duration was 8.2 ± 5.6 years. The median HbA1c was 8.7% (72 mmol/mol). Microvascular complications were present in 14.9% of the patients. The generic HRQoL was lower in patients with T1DM compared to peers without diabetes (77.43 vs. 87.45; p < 0.001). Parents reported lower scores in diabetes management, treatment barriers, physical functioning and generic scales compared to patients. Parents reported greater worry about the disease with lesser age of onset of diabetes and with presence of complications. Those using insulin vials and on splitmix regimen had lower HRQoL compared to those using insulin pens. The patients belonging to lower socioeconomic status (SES) reported lower diabetes scores (73.7 vs. 58.7; p = 0.015). Conclusions: The generic HRQoL was lower in children with T1DM compared to peers without diabetes. Parents and children had different perception about HRQoL in many aspects. The diabetes specific scores were lower in those belonging to lower SES. [ABSTRACT FROM AUTHOR]

Background: Subclinical diastolic dysfunction in patients with Type 1 diabetes mellitus (T1DM) caused by myocardial injury due to diabetic cardiomyopathy leads to a high risk of death and heart failure. This myocardial injury extends not only to the left ventricle (LV) but also to the left atrium (LA). However, LA function in children and young adults with T1DM has not been extensively studied. Objective: Therefore, the aim of this study was to assess LA dysfunction in pediatric and adult patients with T1DM using LA strain analysis with echocardiography. Subjects: Fifty‐three patients (median age: 23 [range: 5–41] years) with T1DM. Methods: We divided the patients into three age groups (D1: 5–14 years, D2: 15–24 years, D3: 25–41 years); 53 age‐ and sex‐matched controls were divided into three corresponding groups (C1, C2, and C3). LA and LV functions were evaluated using echocardiography. Results: LA reservoir strain was lower in the D2 and D3 groups than in the C2 and C3 groups (P = 0.001, P = 0.004, respectively). LA conduit strain was lower in the D2 group than in the C2 group (P = 0.002). LA stiffness was significantly greater in the D3 group than in the C3 group (P < 0.001). Conclusions: In patients with T1DM, LA phasic function decreased in adolescents and young adults, and LA stiffness increased in adult patients aged >30 years. LA phasic function and LA stiffness can be potentially used as early markers for diastolic dysfunction. [ABSTRACT FROM AUTHOR]

Medical nutrition therapy (MNT) is a vital aspect of management of type 1 diabetes mellitus (T1DM) and should be tailored to ethnic and family traditions and the socioeconomic and educational status of the patient. In this article, we discuss the unique aspects of MNT in children and adolescents with T1DM in the Indian setting, with focus on the challenges faced by patients, dieticians and physicians and how these can be overcome. The authors reviewed the available literature on MNT in T1DM from India and prepared the document based on their vast collective clinical experience in treating patients with T1DM from different regions in India. Indian diets are predominantly carbohydrate‐based with high glycemic index (GI) and low protein content. Various methods are available to increase the protein and fiber content and reduce the GI of food in order to limit glycemic excursions. Insulin regimens need to be tailored to the child's school timings, meal schedule, and the availability of a responsible adult to supervise/administer insulin. All patients, irrespective of economic and education background, should be taught the broad principles of healthy eating, balanced diet and carbohydrate counting. There are various barriers to dietary compliance, including joint family system, changing lifestyles, and other factors which need to be addressed. There is a need to customize dietary management according to patient characteristics and needs and develop standardized patient educational material on principles of healthy eating in various regional languages. [ABSTRACT FROM AUTHOR]

Objective: We undertook a 24‐month prospective observational single‐center real‐world trial to study impact of access to intermittently scanned continuous glucose monitoring (isCGM) on quality of life (QOL) and glycemic control of youth with type 1 diabetes (T1D). Methods: Between September 2016 and November 2017, 138 children and adolescents with T1D were recruited. Demographic, metabolic, and QOL data were collected during 24 months of routine follow‐up. Primary endpoint was the evolution of QOL, with secondary outcomes change in HbA1c, occurrence of acute diabetes complications, and school absenteeism. Results: Ninety‐two percent of participants found isCGM more user‐friendly than capillary finger‐stick tests and had high treatment satisfaction, without change in diabetes‐specific QOL. HbA1c significantly increased from 7.2% (7.0‐7.3) (55 mmol/mol [53‐56]) at baseline to 7.6% (7.4‐7.8) (60 mmol/mol [57‐62]) at 12 months (P <.0001) and was unchanged up to 24 months. Overall increase was mainly driven by children with baseline HbA1c <7.0% (<53 mmol/mol). Additionally, BMI adjusted for age was higher at study end. In year before isCGM, 228 days per 100 patient‐years of school absenteeism were reported, which dramatically decreased to 13 days per 100 patient‐years (P =.016) after 24 months. Parents of children also reported less work absenteeism (P =.011). Conclusion: The use of isCGM by T1D pediatrics is associated with high treatment satisfaction and fewer days of school absence. However, increased HbA1c and weight may reflect a looser lifestyle, with less attention to diet and more avoidance of hypoglycemia. Intensive education specifically focusing on these points may mitigate these issues. [ABSTRACT FROM AUTHOR]

Introduction: Youth with type 1 diabetes (T1D) commonly do not meet HbA1c targets. Youth‐directed goal setting as a strategy to improve HbA1c has not been well characterized and associations between specific goal focus areas and glycemic control remain unexplored. Objective: To inform future trials, this analysis characterized intended focus areas of youth self‐directed goals and examined associations with change in HbA1c over a 18 months. Methods: We inductively coded counseling session data from youth in the Flexible Lifestyle Empowering Change Intervention (n = 122, 13‐16 years, T1D duration >1 year, HbA1c 8‐13%) to categorize intended goal focus areas and examine associations between frequency of goal focus areas selected by youth and change in HbA1c between first and last study visit. Results: We identified 13 focus areas that categorized youth goal intentions. Each session where youth goal setting concurrently incorporated blood glucose monitoring (BGM), continuous glucose monitoring (CGM), and insulin dosing was associated with a 0.4% (95% CI: −0.77, −0.01; P =.03) lower HbA1c at the end of intervention participation. No association was observed between HbA1c and frequency of sessions where goal intentions focused on BG only (without addressing insulin or CGM) (β: 0.07; 95% CI: −0.07, 0.21; P =.33) nor insulin dosing only (without addressing BGM or CGM) (β: 0.00; 95% CI: −0.11, 0.10; P =.95). Conclusions: Findings exemplify how guiding youth goal development and combining multiple behaviors proximally related to glycemic control into goal setting may benefit HbA1c among youth with T1D. More research characterizing optimal goal setting practices in youth with T1D is needed. [ABSTRACT FROM AUTHOR]

Objective: To analyze the time trends of nationwide diabetes incidence <15 years of age from 1989 until 2017 in Austria. Methods: The Austrian Diabetes Incidence Study Group registers all newly diagnosed patients with diabetes mellitus <15 years of age in a prospective population‐based study. The diabetes type was classified on the basis of clinical and laboratory findings according to American Diabetes Association criteria. Time trends were estimated by Joinpoint analysis. Results: 1311 patients were diagnosed with type 1 diabetes (T1D) between 1989 and 1999 and 4624 patients with any type of diabetes (1999‐2017). T1D accounted for the majority of cases (94.2%), 1.8% were classified as type 2 (T2D) and 4.0% as other specific types of diabetes (1999‐2017). In the total cohort (age 0 to <15 years), a constant increase until 2012 (annual percent change [APC] 4.5, 95% confidence interval [CI]: 3.94, 5.06) was observed, followed by a leveling off with a corresponding drop (APC 0.28, 95%CI: −3.94, 4.69). This observation was mainly driven by the dynamic in the youngest age group (0‐4 years) with a steep increase until 2007 (APC 7.1, 95%CI: 5.05, 9.19) and a decrease from 2007 to 2017 (APC −0.86, 95%CI: 4.41, 2.82). No significant increase of T2D <15 years was detected. Over the observed time period (APC = 3.7, 95%CI: −0.30, 7.78). Conclusions: The incidence of T1D is declining in young children aged 0 to 4 years, but is still rising in children 5 to 14 years in Austria. Incidence of T2D did not increase significantly and other specific types of diabetes occur twice as often compared to T2D. [ABSTRACT FROM AUTHOR]

Background: Currently, microalbuminuria is the gold standard for detection and prediction of diabetic nephropathy (DN). However, microalbuminuria appears once significant kidney damage has actually occurred. Objectives: We investigated the diagnostic role of urinary Cyclophilin‐A (uCypA), uCypA/creatinine ratio (uCypA/Cr) and serum Cystatin‐C (sCysC) as biomarkers for early detection of DN in children with type 1 diabetes mellitus (T1DM) of short duration (2‐5 years) before microalbuminuria emerges. Methods: uCypA, uCypA/Cr, and sCysC levels were assessed in three age‐ and sex‐matched groups; microalbuminuric diabetic group (n = 31), normoalbuminuric diabetic group (n = 29), and control group (n = 30). Glomerular filtration rate was estimated (eGFR) based on both serum creatinine (eGFR‐Cr) and sCysC (eGFR‐CysC). Results: Significantly higher sCysC and lower eGFR‐CysC were detected in both diabetic groups compared to controls and in microalbuminuric compared to normoalbuminuric group. No detected significant difference in eGFR‐Cr values across the studied groups. Both uCypA and uCypA/Cr were significantly elevated in microalbuminuric compared to both normoalbuminuric and control groups with no difference between normoalbuminuric and control groups. Prediction of microalbuminuria was conducted using sCysC with area under curve up to 0.980. Combined use of sCysC and uCypA had better diagnostic value than uCypA alone. Conclusion: sCysC is a promising early biomarker for DN in childhood T1DM before albuminuria detection. eGFR‐CysC is superior to eGFR‐Cr in evaluating renal status in childhood T1DM. uCypA and uCypA/Cr were useful tools in predicting microalbuminuria, although not regarded as diagnostic biomarkers for early‐stage DN in T1DM children by the current study. [ABSTRACT FROM AUTHOR]

Objective: The incidence of childhood‐onset type 1 diabetes (T1D) has been reported to be rising but there is also evidence that it has been attenuated in recent years. We described the time trends and the incidence of T1D in children in Hong Kong from 2008 to 2017 and compared with the previous local registry in 1997 to 2007. Methods: Data were extracted from the Hong Kong Childhood Diabetes Registry, which was established in 2016. It consists of a retrospective registry (including all childhood diabetes diagnosed in 2008 to 2015) and a prospective registry (including all T1D children diagnosed from 2016 onwards). All T1D children diagnosed at the age of less than 18 years from 1 January 2008 to 31 December 2017 and managed in the public system were included in this study. Results: For the incident years in the 2008 to 2017 period, a total of 498 children with T1D was identified. The crude incidence rate was 4.3 per 100 000 person/year (95% confidence interval 3.96‐4.72), which was much higher than the last registry of 2.2 per 100 000 persons/year. Using general linear model, the increment is statistically significant (P =.02). When compared to the last registry, the rate of increment had attenuated, with annual increment in crude incidence in the two periods for T1D <15 years changing from 4.3% to 3.5% (P =.02). Conclusions: The incidence of T1D children increased significantly in the past two decades in Hong Kong, but the rate of increase had attenuated in recent years. [ABSTRACT FROM AUTHOR]

Objectives: The American Diabetes Association (ADA) and the International Society for Pediatric and Adolescent Diabetes (ISPAD) have outlined standards for best practices in providing optimal diabetes care to children with type 1 diabetes (T1D). Our objectives were to design a metric that evaluated delivery of optimal diabetes care and to use this metric to drive improvement within our diabetes program. Methods: Using published guidelines, we identified 11 elements of optimal diabetes care that should be reliably delivered at our institution as standard‐of‐care. We utilized our electronic medical record to aid in data collection and to notify staff when to deliver specific care elements (eg, lipid collection, depression screening, etc.). We designed the T1D Care Index (T1DCI), a metric which aggregates missed opportunities to deliver elements of optimal diabetes care over a given period into a cumulative score, with a lower T1DCI reflecting better care delivery and improved program performance. Results: Tracking the T1DCI permitted recognition of areas to focus on quality improvement efforts, guided interventions to improve processes for care delivery, and helped determine the allocation of time and resources. Interventions resulted in improvement of care delivery across some elements of care. Overall, we observed a 26% reduction in the T1DCI after 12 months of utilization. Conclusions: The T1DCI is a powerful metric to evaluate the ability of our diabetes program to standardize, quantify, and monitor delivery of optimal diabetes care to children with T1D, and to drive our program toward zero missed opportunities for quality care delivery. [ABSTRACT FROM AUTHOR]

Background/objective: The importance of metabolic control in childhood regarding excess risk of death in young persons has not been well studied. This registry‐based study aimed to investigate mortality rates and cause of death related to metabolic control in young persons (≤29 years) in Sweden with type 1 diabetes. Methods: All 12 652 subjects registered in the Swedish pediatric diabetes quality register, from 2006 to 2014, were included. Data were merged with the Swedish Cause of Death Register. Standardized mortality rates were calculated using the official Swedish population register. Results: Of 68 deaths identified, 38.2% of the deaths were registered as being due to diabetes whereof the major cause of death was acute complications. Overall standardized mortality ratio was 2.7 (2.1‐3.4, 95% CI). Subjects who died from diabetes had a mean HbA1c of 74 ± 19 mmol/mol (8.9 ± 1.7%) during childhood vs 62 ± 12 mmol/mol (7.8 ± 1.1%) in those still alive (P <.001). Conclusions: In this nationwide cohort of young subjects with type 1 diabetes, there was a high mortality rate compared to the general population. Mean HbA1c in childhood was significantly higher in those who died from diabetes, compared to subjects who were still alive. To decrease mortality in young persons with type 1 diabetes it is essential not only to achieve but also to maintain a good metabolic control during childhood and adolescence. [ABSTRACT FROM AUTHOR]

Objective: Type 1 diabetes mellitus (T1DM) in adolescent patients is often characterized by poor glycemic control. This study aimed at exploring the contribution of learning with computerized simulations to support: (a) mechanistic understanding of the biochemical processes related to diabetes; (b) diabetes self‐management knowledge; and (c) glycemic control. We hypothesized that learning with such simulations might support adolescents in gaining a better understanding of the biochemical processes related to glucose regulation, and consequently improve their glycemic control. Methods: A prospective case‐control study was conducted in 12‐ to 18‐year‐old adolescents with T1DM (n = 85) who were routinely treated at an outpatient diabetes clinic. While the control group (n = 45) received the routine face‐to‐face follow‐up, the intervention group (n = 40) learned in addition with computerized simulations that were embedded in pedagogically supportive activities. Participants in both groups completed a set of questionnaires regarding sociodemographic characteristics, diabetes mechanistic reasoning and diabetes self‐management. Clinical data and serum glycated hemoglobin (HbA1c) levels were gathered from medical records. All the data was collected at recruitment and 3 months later. Results: Analysis revealed improvement HbA1c levels in the intervention group (8.7% ± 1.7%) vs the controls (9.6% ± 1.6%) after 3 months (P <.05). Regression analysis showed that levels of diabetes mechanistic understanding and diabetes self‐management knowledge, in addition to sociodemographic parameters, accounted for 31% of the HbA1c variance (P <.001). Conclusion: These results suggest that learning with computerized simulations about biochemical processes can improve adolescents' adherence to medical recommendations and result in improved glycemic control. Implementing scientific learning into the hospital educational setting is discussed. [ABSTRACT FROM AUTHOR]

Background: Across all age groups, management of type 1 diabetes (T1D) places substantial responsibility and emotional burden upon families. This study explored parent perceptions of the burdens of caring for very young children with T1D. Methods: Semi‐structured qualitative interviews were conducted with parents (85% mothers) of 79 children with T1D, aged 1 to <8 years old, from four diverse pediatric diabetes clinical centers. Interviews were transcribed, coded, and analyzed using hybrid thematic analysis to derive central themes. Results: Youth (77% White) had T1D for ≥6 months: age (M ± SD) 5.2 ± 1.5 years, diabetes duration 2.4 ± 1.3 years, and A1c 63 ± 10 mmol/mol (7.9 ± 0.9%); 66% used an insulin pump and 61% used CGM. Three major themes emerged related to diabetes burdens: (a) the emotional burden of diabetes on themselves and their children, (b) the burden of finding, training, and trusting effective secondary caregivers to manage the child's diabetes, and (c) suggestions for how more comprehensive, personalized diabetes education from healthcare providers for parents and secondary caregivers could help reduce parent burden and worry. Conclusions: In families with very young children with T1D, parental perceptions of the burden of managing diabetes are common and could be mitigated by tailored education programs that increase parent knowledge, bolster parents' confidence in themselves, and increase trust in their secondary caregivers to manage diabetes. Reduced parental burden and increased caregiver knowledge may positively impact child's glycemic control, as well as improve parent and child quality of life. [ABSTRACT FROM AUTHOR]

Background/Objective: Poor early glycemic control in childhood onset type 1 diabetes (T1D) is associated with future risk of acute and chronic complications. Our aim was to identify the predictors of higher glycated hemoglobin (HbA1c) within 24 months of T1D diagnosis in children and adolescents. Methods: Mixed effects models with fractional polynomials were used to analyze longitudinal data of patients <19 years of age, followed from T1D diagnosis for up to 2 years, at three diabetes clinics in East London, United Kingdom. Results: A total of 2209 HbA1c observations were available for 356 patients (52.5% female; 64.4% non‐white), followed from within 3 months of diagnosis during years 2005 to 2015, with a mean ± SD of 6.2 ± 2.5 HbA1c observations/participant. The mean age and HbA1c at diagnosis were 8.9 ± 4.3 years and 10.7% ±4.3% (or expressed as mmol/mol HbA1c mean ± SD 92.9 ± 23.10 mmol/mol) respectively. Over the 2 years following T1D diagnosis, HbA1c levels were mostly above the National Institute for Health, Care and Excellence (NICE), UK recommendations of 7.5% (<58 mmol/mol). Significant (P <.05) predictors of poorer glycemic control were: Age at diagnosis (12‐18 years), higher HbA1c at baseline (>9.5%, ie, >80 mmol/mol), clinic site, non‐white ethnicity, and period (pre‐year 2011) of diagnosis. Additionally in univariable analyses, frequency of clinic visits, HbA1c at diagnosis, and type of insulin treatment regimen showed association with poor glycemic control (P <.05). Conclusions: Major risk factors of poorer glycemic control during 3‐24 months following childhood onset T1D are: diagnosis prior to 2011, higher HbA1c levels at baseline, age at diagnosis, non‐white ethnicity, and clinic site. [ABSTRACT FROM AUTHOR]

Objectives: This study sought to: (a) assess the prevalence of diabetes complications and comorbidities screening as recommended by the American Diabetes Association (ADA) for youth and young adults (YYAs) with type 1 diabetes (T1D), (b) examine the association of previously measured metabolic status related to diabetes complications with receipt of recommended clinical screening, and (c) examine the association of satisfaction with diabetes care with receipt of recommended clinical screening. Methods: The study included 2172 SEARCH for Diabetes in Youth participants with T1D (>10 years old, diabetes duration >5 years). Mean participant age was 17.7 ± 4.3 years with a diabetes duration of 8.1 ± 1.9 years. Linear and multinomial regression models were used to evaluate associations. Results: Sixty percent of participants reported having three or more hemoglobin A1c (HbA1c) measurements in the past year. In terms of diabetes complications screening, 93% reported having blood pressure measured, 81% having an eye examination, 71% having lipid levels checked, 64% having a foot exam, and 63% completing albuminuria screening in accordance with ADA recommendations. Youth known to have worse glycemic control in the past had higher odds of not meeting HbA1c screening criteria (OR 1.11, 95% CI = 1.05, 1.17); however, after adjusting for race/ethnicity, this was no longer statistically significant. Greater satisfaction with diabetes care was associated with increased odds of meeting screening criteria for most of the ADA‐recommended measures. Conclusions: Efforts should be made to improve diabetes complications screening efforts for YYAs with T1D, particularly for those at higher risk for diabetes complications. [ABSTRACT FROM AUTHOR]

Objective: Patient‐reported outcomes have received increased attention as treatment outcomes and indicators of wellbeing. A1c has been criticized as lacking patient‐centered relevance because individuals are often unaware of their A1c, and studies also often fail to show a benefit of intensive control on quality of life. The goal of the present study was to examine self‐rated health (SRH) in relation to diabetes self‐care behaviors, socioeconomic factors, treatment regimen characteristics, and glycemic control among predominately Hispanic and African American adolescents with type 1 diabetes (T1D). Methods: Adolescents with T1D (N = 84) were recruited for a cross‐sectional study evaluating psychosocial factors and identity development. SRH, self‐care behaviors, treatment regimen, and demographic variables were collected through self‐report while glycemic control (A1c) was determined through chart review. Results: Participants were predominantly racial and ethnic minorities (48% Hispanic, 27% African American; 52% female, M age 15.9, M diabetes duration 6.8, M A1c 10% [86 mmol/mol]). Significant bivariate relationships emerged between SRH and sex, A1c, self‐care behavior, and insulin delivery method. Covariate‐adjusted regression models showed only A1c was significantly and independently related to SRH. Mediation analyses illustrated a significant indirect effect for A1c between self‐care and SRH. Conclusion: These findings suggest glycemic control is associated with self‐ratings of health among ethnically diverse adolescents with T1D. SRH appears to be an appropriate patient‐reported outcome that is sensitive to glycemic control in this population. [ABSTRACT FROM AUTHOR]

Background: Cardiac dysfunction is a complication of type 1 diabetes mellitus (T1DM) with primary concern in adults. However, studies have evaluated left ventricle (LV) myocardial changes in pediatrics but not the long‐term effect of T1DM in such vulnerable age. Therefore, we assessed LV functions in pediatric patients with long‐duration T1DM using different echocardiographic modalities. Methods: Between July 2015 and March 2016, 48 T1DM patients were prospectively compared to 35 healthy controls. Pediatric patients with T1DM for 10 years or more were included in the study. Patients were subjected to history taking, clinical examination, glycated hemoglobin (HbA1c), and microalbuminuria measurements. Moreover, conventional echocardiography, tissue Doppler, and 2D speckle tracking were performed to analyze LV functions. Results: Mean age of patients was 15.5 ± 2 years, and mean T1DM duration was 11.7 ± 1.8 years. LV dimensions, EF and FS, and mass index did not statistically differ between groups, but E/E′ ratio was significantly higher in the diabetic group. Global longitudinal strain (GLS) and global circumferential strain (GCS) were significantly lower in diabetic patients compared with controls (P = 0.038; P = 0.001, respectively). Mean HbA1c was found to be a significant predictor of decreased GLS in the diabetic population (95% CI, 0.096‐0.244; P = 0.001) but not predicting GCS. Microalbuminuria had no significance in predicting strain. Conclusions: Despite the long‐duration of affection with T1DM during childhood in our patients, alterations on LV myocardial function could not be detected either clinically or by conventional echocardiography. Tissue Doppler and speckle tracking could be used in the follow up of myocardial status in pediatric diabetic patients. [ABSTRACT FROM AUTHOR]

Objective: Youth with type 1 diabetes (T1D) endorse high rates of depressive symptoms, which can significantly impair self‐management, glycemic control, and quality of life. Current guidelines recommend annual depression screening for all adolescents with T1D, but few models exist to implement screening procedures across clinics in this population. The primary aim of this project was to increase depression screening from 0% to 80% in four clinics, and to describe the structured quality improvement process to reach this goal. Methods: All patients aged 12 to 21 years old with T1D at four participating clinics in a Midwestern hospital system were eligible to participate. Using a two‐stage process, patients were administered the Patient Health Questionnaire (PHQ‐2 plus PHQ‐9 if positive) annually. Rates of depression screening by clinic site, rates of positive depression screens, social worker documentation of follow‐up care, and associations with diabetes‐related health outcomes were analyzed. Results: Over 2 years, average depression screening rates increased from 0% to 75% across all clinics, and 89% of patients with a positive screen met with a social worker for a targeted mental health assessment. At initial screening, 7.6% of patients screened positive for at‐risk depressive symptoms on the PHQ‐2 and from that group, 6.7% additionally screened positive on the PHQ‐9. Conclusions: Annual depression screenings were feasibly implemented across four clinics and the use of real‐time data listening and automated processes facilitated successful implementation. Future directions include further automation, targeted training and billing mechanisms, dissemination to non‐metropolitan clinics, and further assessment of depression screening tools for adolescents with T1D. [ABSTRACT FROM AUTHOR]

Background: Vitamin D metabolism has been associated with type 1 diabetes. Objective: We aimed to clarify the association of 25‐hydroxylase (CYP2R1) and 1α‐hydroxylase (CYP27B1) with risk of developing type 1 diabetes in Korean children. Methods: In total, 252 children (96 type 1 diabetes and 156 healthy controls) under the age of 20 years were recruited. Serum 25‐hydroxyvitamin D (25OHD) and 1α,25‐dihydroxyvitamin D [1α,25(OH)2D] levels were determined. Allelic, genotypic, and haplotypic distribution of CYP2R1 (rs12794714, rs10766196, rs10741657, rs2060793, and rs10766197) and CYP27B1 (rs4646536, rs10877012, and rs3782130) polymorphisms were determined. Clinical and biochemical data were analyzed according to genotype. Results: Mean vitamin D level was considerably lower, and vitamin D deficiency was more prevalent in children with type 1 diabetes than in healthy controls. The GG genotype of CYP2R1 rs12794714 and AA genotype of CYP2R1 rs10766196 were significantly associated with risk of developing type 1 diabetes (odds ratio 2.00, 95% confidence interval 1.176‐3.413 and odds ratio 1.88, 95% confidence interval 1.103‐3.195, respectively). The GG+GA genotype of CYP2R1 rs12794714 and AA+AG genotype of CYP2R1 rs10766196 were associated with prevalent vitamin D deficiency in children with type 1 diabetes. These genotypes did not differ with respect to glycosylated hemoglobin and daily insulin requirement. Conclusions: Serum 25OHD and 1α,25(OH)2D levels were lower in children with type 1 diabetes than in healthy controls. CYP2R1 rs12794714 and rs10766196 polymorphisms were associated with a higher risk of type 1 diabetes. Thus, polymorphisms in vitamin D metabolism may contribute to susceptibility to type 1 diabetes in Korean children. [ABSTRACT FROM AUTHOR]

Background: Diabetic ketoacidosis (DKA) is the leading cause of morbidity and mortality in children with type 1 diabetes (T1D). Little is known about the association between genetic and immunological markers and the risk for DKA at onset of T1D. The aim of this study was to create a model foreseeing the onset of DKA in newly diagnosed patients. Methods: This retrospective study included 532 T1D children (aged <18 years at diagnosis) recruited in our hospital, from 1995 to 2014. DKA and its severity were defined according to the criteria of ISPAD. Genetic risk categories for developing T1D were defined according to the Belgian Diabetes Registry. Multivariate statistical analyses were applied to investigate risk factors related to DKA at diagnosis. Results: Overall 42% of patients presented DKA at diagnosis. This study outlined the major risk of DKA at diagnosis for younger children (<3 years) and for those belonging to ethnic minorities. Children carrying neutral genotypes had a 1.5‐fold increased risk of DKA at diagnosis than those with susceptible or protective genotypes, a paradoxical observation not previously reported. Only solitary positive IA‐2A increased the risk of DKA at diagnosis. The proposed model could help to predict the probability of DKA in 70% of newly diagnosed cases. Conclusions: This was the first reported implication of IA‐2A positivity and neutral genotypes predisposing to DKA at diagnosis regardless of its severity. Earlier diagnosis through genetic and immunological screening of high‐risk children could decrease DKA incidence at diabetes onset. [ABSTRACT FROM AUTHOR]

Objective: Psychiatric diagnoses of patients with type 1 diabetes mellitus (T1DM), the severity of attention deficit/hyperactivity disorder (ADHD) symptoms of the patients and their primary caregivers, and the effects of these factors on treatment were investigated. Methods: Sixty‐one patients with T1DM were included in the study along with their parents. Psychiatric diagnoses of the patients were determined using a semistructured psychiatric interview, and their depression and ADHD symptom severities were evaluated with self‐report scales. The ADHD symptom severities of the parents were evaluated using self‐report scales. The relationships among the psychiatric symptoms and the hemoglobin A1c (HbA1c), fasting blood glucose (FBG), and postprandial blood glucose (PBG) levels of the patients were investigated. Results: HbA1c levels were found to correlate with the hyperactivity levels of children and the number of diagnoses they had. FBG and PBG values of patients diagnosed with ADHD were found to be higher than in those who did not have ADHD. HbA1c, FBG, and PBG values of the patients who had any disruptive behavior disorder were found to be higher than in those who did not. ADHD total scores, gender (being female), having diagnoses of ADHD or depression were found to be predictive of HbA1c levels according to the regression analyses. No relationship between the clinical findings of the children and their parents' ADHD levels was found. Conclusions: The findings of this study implicate that children with T1DM should be evaluated in terms of ADHD which could have negative effects on the treatment. [ABSTRACT FROM AUTHOR]

Objective: To evaluate primary care presentations during the prodrome (12 months prior to onset type‐1 diabetes (T1D), with or without diabetic ketoacidosis [DKA]), to identify opportunities for earlier diagnosis. Methods: This was a case‐control study, linking 16 years of data from children (≤15 years) registered at diagnosis of T1D, and routinely collected primary care records in Wales (United Kingdom). Controls (without T1D) were matched on a 3:1 ratio. Conditional logistic regression modeling was used to compare characteristics occurring in cases (children with T1D) and controls; and cases that presented with/without DKA. Results: A total of 1345 children with T1D (19% DKA) and 4035 controls were identified. During the 12 months prior to diagnosis, cases were 6.5 times more likely to have at least one primary care contact (P < 0.001). One to 30 days prior to diagnosis, contacts relating to blood tests, fungal conditions, respiratory tract infections (RTIs), urinary conditions, vomiting, and weight were independently associated with T1D, as were contacts relating to blood tests, between 91 and 180 days prior to diagnosis. Children with a contact up to a month prior to diagnosis, relating to RTIs, antibiotic prescriptions, and vomiting, were more likely to present in DKA, as were boys (P = 0.047). Conclusion: There are opportunities in primary care for an earlier diagnosis of T1D in childhood. These data could be used to create a predictive diagnostic tool, as a potential aid for primary care health professionals, to prevent presentation in DKA. [ABSTRACT FROM AUTHOR]

Background: Recent studies have suggested that there is an earlier age of onset of puberty in healthy boys. However, no study has determined the age of pubertal development in boys with type 1 diabetes (T1D) and compared the results with a simultaneously recruited group of healthy children. Objective: The aim of this study was to evaluate the age of pubertal events in boys with TD1 and determine whether the duration of diabetes, metabolic control or insulin dose are associated with the age of puberty in boys with T1D. Methods: Boys aged 7 to 19 years with T1D (n = 148, age 12.9 ± 3.0 years) and healthy boys recruited from schools (n = 388 controls, age 12.8 ± 2.2 years) were studied. A pediatric endocrinologist evaluated pubertal development. Results: Boys at genital Tanner stage 2 and the final stages of puberty (genital Tanner 4 and 5) were younger than the control group (P = 0.005, P = 0.003, and P = 0.015, respectively). Both groups of boys had a similar age of pubic Tanner stage development. There were no cases of pubertal delay observed in the T1D cohort. There was no association observed between metabolic control with pubertal timing. T1D adolescents had lower height‐SDS than the C group at the final stages of puberty. Conclusions: Boys with T1D who are treated with modern insulin therapy appear to have an earlier age of onset and an earlier age of final pubertal events than a simultaneously studied group of healthy children. These data suggest that pubertal delay is not a frequent problem for male T1D patients. [ABSTRACT FROM AUTHOR]

Objective: Data regarding the association between hypoglycemia and attention deficit hyperactivity disorder (ADHD) in children and adolescents with type 1 diabetes mellitus (T1DM) are limited. This study investigated whether hypoglycemia was associated with the risk of ADHD in young people with T1DM. Methods: Children and adolescents with a diagnosis of T1DM were identified from the Longitudinal National Health Insurance Database in Taiwan from 1998 to 2011. Among them who were newly diagnosed with hypoglycemia during 2000 to 2007 were selected for the hypoglycemia cohort. The hypoglycemia diagnosis date was defined as the index date. Those who were diagnosed with ADHD before the index date were excluded. The main outcome was the development of ADHD. In total, 726 participants with hypoglycemia and 2852 participants without hypoglycemia were included in this study. Results: The overall incidence density of ADHD was markedly increased among cohort with hypoglycemia compared with cohort without hypoglycemia (4.74 vs 1.65 per 1000 person‐years), with an adjusted hazard ratio (aHR) of 2.73 (95% confidence interval [CI] = 1.50‐4.98). Cohort with hypoglycemia who had experienced a hypoglycemic coma had a significantly higher risk of ADHD (aHR = 6.54, 95% CI = 1.89‐22.7) compared with cohort without hypoglycemia. Conclusions: Hypoglycemia, especially hypoglycemic coma, is significantly associated with a subsequent risk of ADHD in young people with T1DM. [ABSTRACT FROM AUTHOR]

Diabetic ketoacidosis (DKA) is one of the most common causes of morbidity and mortality in new onset type 1 diabetes mellitus (T1DM). Children have a higher rate of neurological complications from DKA when compared to adults. The differential for sudden focal neurological deterioration in the setting of DKA is cerebral oedema followed by ischaemic and haemorrhagic stroke. Spontaneous intracranial haemorrhages can present with non‐specific features frequently, for example, impaired consciousness, even when biochemical parameters are improving in the setting of DKA. We report the case of a girl with new onset T1D who presented in severe DKA and subsequently developed intracerebral parenchymal and subarachnoid haemorrhages. Our patient is unique in that no focal neurological or neuropsychological deficits have been found at 1‐year follow up, compared to the literature which suggests poor outcomes. Our case contrasts with these previous cases as none of the other case reports demonstrated subarachnoid haemorrhages with survival. [ABSTRACT FROM AUTHOR]

Objective: To examine cross‐sectional and longitudinal associations among parenting styles (ie, authoritative, authoritarian, and permissive) and youth glycated hemoglobin (HbA1c) in a cohort of families of children with new‐onset type 1 diabetes (T1D). Methods: One‐hundred two parents completed a baseline measure of parenting style, and we collected child HbA1c values at baseline and at three‐ and six‐month follow‐ups. We examined correlations among use of different parenting strategies and child HbA1cs. We conducted multiple regressions to assess the impact of these strategies on child HbA1c at three‐month and six‐month follow‐ups, while controlling for baseline HbA1c, family income, and T1D duration. Results: Correlational analyses showed negative associations between authoritative strategies and child HbA1c at baseline, three‐month, and six‐month assessments and positive associations between authoritarian strategies and child HbA1c at three‐month and six‐month assessments. Regression analyses found use of authoritarian‐like strategies were the only parenting strategies associated with child HbA1c at three‐month and six‐month follow‐ups, while controlling for baseline HbA1c, family income, and T1D duration. Conclusion: Parents' use of authoritarian‐like strategies may negatively impact glycemic control over the course of six‐month in children with new‐onset T1D. [ABSTRACT FROM AUTHOR]

Background: The study aimed to assess accuracy, satisfaction and usability of a flash glucose monitoring system (FGM) in children and adolescents with type 1 diabetes mellitus (T1DM) attending a diabetes summer camp. Methods: Sixty‐six children and adolescents with T1DM aged 6 to 17 years participating in a 7‐day medically supervised summer camp were enrolled. Capillary blood glucose (BG) and flash glucose (FG) values were measured simultaneously at breakfast, lunch, and dinner and for any given FG value <72 mg/dL (<4.0 mmol/L) during daytime, <108 mg/dL (<6.0 mmol/L) at nighttime, >270 mg/dL (>15.0 mmol/L) or when patient symptoms were discordant with sensor readings. Sensor‐related issues were documented and patients' and healthcare professionals' (HCPs) satisfaction was evaluated. Results: FGM demonstrated satisfactory clinical accuracy compared to reference capillary BG values with 98.8% of values falling within the clinically acceptable zones (A and B) of the consensus error grid. Overall mean absolute relative difference (MARD) was 16.7% ± 16.1%. Specific calculations of mean absolute difference (MAD), mean relative difference (MRD), and mean difference (MD) demonstrated that FGM overestimated BG values across all glycemic ranges. Overall satisfaction with the FGM was high in 91.7% participants and 95.0% HCPs, although confidence in the system was low in 18.0% participants and 40.0% HCPs. Conclusions: The FGM exhibited satisfactory clinical accuracy. However, based on the present data, we conclude that no decision should be taken on the basis of a single, non‐verified, FGM value alone. Our study highlights the need for revised therapeutic education for patients/families and further investigation on the integration of sensor readings in clinical decision‐making. [ABSTRACT FROM AUTHOR]

Adherence to treatment regimen is associated with improved glycemic control and is particularly problematic during adolescence for those with type 1 diabetes mellitus (T1DM). Both glycemic control and adherence may be negatively impacted by poor psychological outcomes in adolescence, such as depressive symptoms and low hopefulness. The purpose of this study was to examine associations between the mealtime insulin bolus score (BOLUS), a more robust proxy measure of adherence than frequency of blood glucose monitoring or self‐report, with depressive symptoms, hope, and hemoglobin A1c (HbA1c). Ninety adolescents completed measures of hope (Children's Hope Scale) and depressive symptoms (Center for Epidemiologic Studies—Depression Scale), as well as lab‐based measures of HbA1c and mealtime insulin bolus scores (BOLUS). Higher levels of hope were associated with lower levels of depressive symptoms, more frequent mealtime insulin boluses, and better glycemic control. Higher levels of BOLUS behavior were associated with lower depressive symptoms and better glycemic control. Both BOLUS behavior and hope independently and significantly impacted the relationship between depressive symptoms and HbA1c, suggesting a possible mediation. Since hope and BOLUS were each associated with the relationship between depressive symptoms and glycemic control, following confirmation of this relationship in a longitudinal study, clinics may consider measuring hope and BOLUS among youth with high depressive symptoms and further investigating BOLUS behavior and hope as potential intervention targets to improve glycemic control. [ABSTRACT FROM AUTHOR]

The extant literature finds that children with type 1 diabetes mellitus (T1D) experience mild cognitive alterations compared to healthy age‐matched controls. The neural basis of these cognitive differences is unclear but may relate in part to the effects of dysglycemia on the developing brain. We investigated longitudinal changes in hippocampus volume in young children with early‐onset T1D. Structural magnetic resonance imaging data were acquired from 142 children with T1D and 65 age‐matched control subjects (4‐10 years of age at study entry) at 2 time points, 18 months apart. The effects of diabetes and glycemic exposure on hippocampal volume and growth were examined. Results indicated that although longitudinal hippocampus growth did not differ between children with T1D and healthy control children, slower growth of the hippocampus was associated with both increased exposure to hyperglycemia (interval HbA1c) and greater glycemic variability (MAGE) in T1D. These observations indicate that the current practice of tolerating some hyperglycemia to minimize the risk of hypoglycemia in young children with T1D may not be optimal for the developing brain. Efforts that continue to assess the factors influencing neural and cognitive development in children with T1D will be critical in minimizing the deleterious effects of diabetes. [ABSTRACT FROM AUTHOR]

Objective: To evaluate longitudinal serum insulin‐like growth factor‐I (IGF‐I) in a large cohort of children and adolescents with type 1 diabetes in relation to hemoglobin A1c (HbA1c), age, diabetes duration, and body mass index (BMI), its association to height and retinopathy, and in comparison with healthy subject references. Methods: A total of 2683 serum IGF‐I values were obtained from 806 children and adolescents with T1DM, from annual blood samples for up to 6 consecutive years. Results: In a multiple regression analysis IGF‐I values were negatively correlated to HbA1c and diabetes duration, and positively correlated to BMI (P < .001, P < .001, and P < .001, respectively, adjusted r2 = 0.102). Children and adolescents with T1DM had lower mean IGF‐I levels and reference interval limits compared to healthy subjects. In boys, mean (SD) IGF‐I SD score (SDS) levels were −1.04 (±1.3) calculated from the healthy reference. IGF‐I peaked at 15 years of age, similarly to healthy controls, but with markedly lower levels in late puberty. Girls were more affected at later stages of puberty but with a slightly less depressed overall mean IGF‐I SDS of −0.69 (±1.2). In a subgroup of 746 subjects with fundus photography, a negative correlation was seen between individual mean IGF‐I SDS and preproliferative retinopathy (P = .004, adjusted r2 = 0.021). In another subgroup of 84 adolescents, no correlation was seen between individual mean IGF‐I SDS and target height SDS or distance to target height SDS. Conclusion: Poor metabolic control and diabetes duration impact negatively on serum IGF‐I levels. A low individual mean IGF‐I level was associated with progression of retinopathy independently of HbA1c, age, gender, and diabetes duration. Disease, sex and age related IGF‐I SDS may become clinical helpful as a supplement to HbA1c in predicting the long‐term outcome for children and adolescents with T1DM. [ABSTRACT FROM AUTHOR]