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.
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.
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.