Technology is Great, but Most Kids with Diabetes Still Need More Help (ADA 2021)

Recent decades have brought incredible advances in diabetes technology, but children and teens are still struggling to meet recommended glycemic targets.

There are almost a quarter-million young people in the US with diabetes (more than 75% with type 1 diabetes), according to the American Diabetes Association. For youth especially, early detection and optimal management are of utmost importance; with many decades of life ahead, keeping blood glucose levels in check today can help reduce unpleasant (and deadly) diabetic complications decades down the road. Prudent diabetes management also has immediate benefits and can have a huge impact on quality of life.

What’s the scope of the problem, and what can be done about it? Scientists at the American Diabetes Association (ADA) 81st virtual Scientific Sessions relayed the striking results of several studies on the state of things today for kids and teens with diabetes. Here are some of the most notable findings.

Youth A1c’s Are Not Improving

It has long been the case, unfortunately, that the majority of pediatric diabetes patients routinely do not meet their treatment goals, most often assessed via quarterly A1c testing. A team of researchers across the US reported on recent trends in recently diagnosed youth, as part of the SEARCH for Diabetes in Youth initiative. The major conclusion?

HbA1c levels remained stable but higher than recommended across discrete cohorts of SEARCH youth with type 1 diabetes duration ≤ 30 months, particularly among non-white youth.

In fact, the average A1c levels among young people with diabetes remain quite high; despite rapid advancement in technology use and newer insulin formulations, the report shows no significant change between average A1c levels between 2002 and 2016. The average A1c held steady at about 7.9%.

How Much is Technology Helping?

Now, for some better news. It appears that early use of continuous glucose monitoring (CGM) technology is associated with lower A1c levels. As reported by Dr. Priya Prahalad of Stanford Children’s Health, newly-diagnosed youth (2018-2020) who were offered CGM initiation early on had markedly lower A1c levels than those from a previous cohort that did not initiate CGM therapy.

Unfortunately, while the A1c differences between the two groups were significantly different at 6, 9, and 12 months after diagnosis, the average A1c level was still at or above 7%, for a considerable proportion of study participants. These results underscore the value of CGM use in improving diabetes management in young people, but also demonstrate the need for more effective management strategies in this group.

Trouble at School

A report from Dr. Christine March and her team at the University of Pittsburgh illustrated the unique challenges that children face on school days vs. weekends. In this study, CGM data from hundreds of children with diabetes were analyzed to assess trends in blood glucose levels (specifically, the time-in-range, TIR metric) across hours of the day and night, as well as on weekdays vs. weekends. The main result?

For weekday school hours, median TIR (70-180 mg/dL) was 52.4%; only 34 (15%) of youth met a TIR goal of >70%… Weekday and weekend CGM metrics were clinically similar, though TIR was statistically higher and time high/very high (>180 mg/dL) lower on weekends… Notably, TIR early in the school day was nearly half of TIR during similar weekend hours, perhaps relating to sleep/meal schedules.

Moreover, the team looked at various attributes, like insulin pump use, duration since diabetes diagnosis, and A1c level to see if there was a connection with the time-in-range metric. They report that younger age, shorter diabetes duration, and lower A1c levels were associated with more TIR during school hours. Interestingly, insulin pump use appeared to have no effect in this study.

Technology and Diabetes Distress

Several researchers posited that youths with diabetes and their caregivers have very different perceptions regarding the emotional impact of advanced diabetes technology.

Can Tech Reduce Family Conflict?

One study presented this week sought to determine whether the use of diabetes technology devices improved “family conflict” in teens with type 1 diabetes. In this evaluation of 60 participants, researchers found lower A1c levels in those using closed-loop technology. The technology also led to a significant increase in caregivers reporting lower levels of family conflict surrounding diabetes management. Perhaps surprisingly, the teenagers themselves did not seem to think that family conflict had been reduced by the closed-loop pumps.

Does Tech Alleviate Diabetes Worries, or Exacerbate Them?

A second study suggested that advanced technology use may actually provoke anxiety in children.

Dr. Fatemah Abdulhussein and colleagues from UCSF evaluated whether the use of advanced insulin delivery systems alleviated worry and fear of low blood glucose levels among patients and caregivers. The major findings?

Longer duration of diabetes, duration of pump use, and duration of CGM use were all associated with higher mean worry scores [among children, but not their caregivers].

That’s the cruel paradox of childhood diabetes in a nutshell: the longer a child has had diabetes, the more stress it causes. And superior management tools may only add to the emotional burden, rather than alleviate it.

Management Success Still Leads to Peace of Mind

The UCSF researchers also looked at diabetes treatment satisfaction scores and found that the only variable in the study that was associated with a lower treatment satisfaction score was higher GMI (glucose management indicator). They conclude,

These data suggest that despite recent advancements in diabetes technology, FOH [fear of hypoglycemia] and diabetes treatment satisfaction still remain significant concerns and need to be addressed in clinical contexts.

smartphone to detect depression and loneliness

Photo credit: Adobe Stock

Parents Experience Diabetes Distress, Too.

A lot of burden falls on the diabetes caregiver, too, and understandably so.

A team of researchers based in Washington, DC and Nashville, TN looked at “parental reports of diabetes distress [DD], diabetes-related family conflict, quality of life” along with patient A1c levels. A key finding that that higher A1c levels in young people were associated with a higher incidence of parental diabetes distress, related family conflict, and quality of life. Notably, female caregivers were more likely to experience distress than male caregivers. Researchers summarize,

Importantly, parental DD is related to children’s glycemic control, suggesting that increased psychological support for parents with teens with DD is warranted.

The Takeaways

A1c levels remain steady at about 7.9% for young people with diabetes in the US, still considerably higher than what is recommended by major health organizations. Some research shows that CGM utilization and the use of closed-loop insulin pumps can help improve diabetes management. Of course, cost and access also remain barriers for many when it comes to technology access.

Sadly, even with the use of advanced technology, it appears that patients and caregivers alike experience a considerable amount of distress in dealing with the demanding nature of diabetes management. Perhaps patients and families would benefit from increased emotional support as much as improved access to diabetes technology.

Importantly, A1c levels stood out in several studies as important determinants in patient and caregiver treatment satisfaction, as well as distress levels. Glycemic control should remain a paramount goal, not just for short- and long-term health, but also for emotional wellbeing. Helping youth with diabetes achieve or exceed recommended targets is likely to help lessen the mental burden of diabetes management and improve quality of life and family dynamics in the long term.

Source: diabetesdaily.com

Do Low-Carbohydrate, High-Protein Diets Offer an Advantage? (ADA 2021)

We already know that low-carb diets can be great for glucose control and diabetes management. The evidence is clear: patients with both type 2 diabetes and type 1 diabetes can benefit from the low-carbohydrate approach.

But as the diet has gained acceptance, some specialists have begun to look more carefully at the details and other consequences of the low-carb approach. Does the amount of protein matter? Can carbohydrate restriction have negative effects on lipid profiles, cognition, or mental health parameters?

Here we describe three new study reports just released at the American Diabetes Association (ADA) 81st virtual Scientific Sessions that address some of these topics.

Higher-Protein Diet, Inflammation and Type 2 Diabetes Remission

Many studies have shown that weight loss and improved blood glucose levels can be achieved with a variety of dietary approaches, but does increasing the protein and lowering carbs offer even more advantages for those with diabetes?

Frankie Stenz, MS, PhD, and Associate Professor of Medicine Endocrinology, and her team at the University of Tennessee evaluated the effects of a high-carb (55% CHO and 15% protein) vs. a high-protein (30% protein and 40% CHO) diet in adults with type 2 diabetes for 6 months. They report that the higher-protein approach significantly reduced inflammatory markers (several important cytokines measured in the blood), as compared to the higher-carb group. Inflammation markers are important parameters, especially for those with diabetes, as inflammation is closely linked to insulin resistance. Also, while weight loss was similar between the two groups, those adhering to the higher-protein diet had a significant increase in lean body mass as well as a decrease in fat mass as compared to the higher-carb group.

Moreover, while improved glucose tolerance and and insulin sensitivity occurred in both groups to some degree, diabetes remission occurred in only 16% in the high-carb group, as compared to a striking 100% in the higher-protein group. Remission was defined by the study authors as a lowering of A1c to <6.5%, along with fasting glucose levels of <126 mg/dL and not exceeding 140 mg/dL at two hours post-meal. The researchers conclude,

The HP [High Protein] diet demonstrated improvement in glucose tolerance and insulin sensitivity with 100% remission… and a significant decrease in inflammatory cytokines.

Photo credit: iStock

Lower-Carb, Higher-Protein Diets and Lipid Levels

Effects on blood lipid levels when eating lower-carb (and by extension higher protein and fat) are often a point of controversy, especially when it comes to people with diabetes, who are already at higher risk for heart disease. Heart disease is complex and multifactorial; however, many researchers agree that both blood glucose parameters and lipid profiles can play a significant role. Previous research has produced some mixed results regarding how different diets can affect lipid profiles, with many studies showing improvements in lipid parameters when eating lower-carb.

Most recently, an international team of experts from Denmark and Texas released the results of a new study that evaluated how lower-carb, higher-protein diets affect weight loss and blood lipid profiles in adults with type 2 diabetes. Over a period of six weeks, 72 patients were assigned to a lower-carb, higher-protein diet (30% CHO and 30% protein) vs. a “conventional” eating approach (50% CHO and 17% protein). When weight loss and blood lipid profiles were examined between the groups, the findings demonstrated that while both groups achieved similar levels of weight loss, those in the lower-carb, higher-protein group achieved more of a decrease in their triglyceride and LDL-cholesterol levels, along with a greater increase in HDL-cholesterol levels. Also, they determined that the triglyceride levels in the liver were significantly reduced in this group, as compared to those eating higher-carb. The team concluded that,

Carbohydrate restriction adds to the positive effect of weight loss in T2D patients by inducing greater improvements in atherogenic lipid profile, maybe facilitated by a reduction in intrahepatic fat.

Carbohydrate Restriction, Quality of Life and Cognitive Performance

Do low-carbohydrate eating patterns have effects on cognitive function and mental health?

Nicole J. Jensen and a team from Copenhagen University in Denmark just announced the results of a randomized trial that examined quality of life parameters and cognitive function among “72 adults with type 2 diabetes and overweight and obesity” as a function of diet. One group was assigned to a lower-carb, higher-protein diet (30% CHO and 30% protein) and another to a higher-carb diet (50% CHO and 17% protein) for six weeks. Next, the team looked at weight loss along with mental health parameters and cognitive performance scores between the two groups. While both groups achieved similar weight loss, the study authors reported additional mental health and cognitive benefits in the lower-carb, higher-protein group. They conclude,

Weight loss improves physical health independently of diet composition, and carbohydrate restriction may further benefit mental health, without adversely affecting overall cognition.

Summary

Altogether, these new studies highlight that while weight loss and improvement of blood glucose levels is achievable using various dietary approaches, lower-carb and higher-protein diets appear to confer additional benefits. Namely, lowering carbs and increasing protein consumption can lower inflammation, improve lipid parameters, increase lean muscle mass and fat loss, and further improve glucose levels in adults with type 2 diabetes, as opposed to a more conventional dietary approach. Moreover, a lower-carb, higher protein diet may confer additional mental health benefits and does not negatively affect cognitive performance.

Source: diabetesdaily.com

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