Background and Aims

Little is known about individual perspectives and challenges faced by elite-level athletes living with type 1 diabetes (T1D). Currently, there is no structured tool to assess this. We aimed to generate and pilot test the Diabetes ExErcise Perception (DEEP-1) questionnaire in a group of professional athletes with T1D.

Methods

The questionnaire consists of a range of open and closed questions, focusing on 4 key areas related to T1D and exercise: 1) Technology; 2) Sleep and Recovery; 3) Glucose Management; 4) Nutrition. Sixteen professional cyclists with T1D (age 27±4 years; HbA_1c 6.8±0.5%) were asked to anonymously complete the questionnaire. Data were then analyzed descriptively.

Results

Fifteen participants responded. In this cohort, 90% showed an interest in using technology for improved exercise performance and 89% for glucose management, although 28% felt unaware of newer technologies. Glucose was perceived as being generally well regulated; however, according to the responses, more attention needs to be focused overnight and pre/during exercise. Sleep quality was rated as an important factor affecting exercise performance in 80% of respondents. 93% of participants identified nutrition as an area for improved performance, with 25% reporting a lack of education in this area.

Conclusions

This pilot study highlights the importance of an individualized approach to diabetes management and high-level exercise. Future work should validate the DEEP-1 questionnaire in a larger sample size using a range of physical activity levels. Such a tool may provide a useful and time-efficient means for healthcare professionals to gain deeper insight into their patients’ attitudes and challenges regarding exercise.

Background and Aims

Persons with diabetes commonly engage with continuous glucose monitoring (CGM) systems by viewing data directly. Features such as alerts, real-time sharing, and the ability to retrospectively summarize patterns and trends offer additional opportunities for engagement and additional pathways for therapeutic adjustments. We examined feature set utilization and glycemic outcomes among users of the G6 CGM System (Dexcom).

Methods

Data were from a convenience sample of anonymized US-based G6 users who began use in 2H2019 and who used a compatible mobile device to view and upload data on at least 80% of the days in 1H2020. "Stable" profiles were those with coefficients of variation ≤36%. Use or non-use of five features was considered on each day of 1H2020: CLARITY (software for report generation); Share/Follow (distributes real-time data to remote devices); Urgent Low Soon (triggered by impending hypoglycemia); and Low Threshold and High Threshold (triggered by existing hypoglycemia and hyperglycemia, respectively). Each user was categorized as low-engagement, medium-engagement, or high-engagement based on their mean daily use of features (<3, 3-4, and >4 features, respectively).

Results

Data from 35,993 users (12,079 low-engagement, 15,063 medium-engagement, and 8.851 high-engagement) were analyzed. The Figure shows that the high-engagement group had the highest TIR (62.2%), the lowest proportion of glucose values <54 mg/dL (0.31%), and the highest proportion of users with stable glucose profiles (67.7%). All between-group differences were statistically significant (p<0.001).

Conclusions

Routine engagement with CGM data as evidenced by use of optional features may contribute to favorable glycemic outcomes.

Background and Aims

Burnout in people with diabetes and healthcare professionals is at an all-time high. Spotlight is a novel ‘smart’ adaptive dynamic patient questionnaire designed to improve routine outpatient consultations by rapidly identifying patient priorities and presenting these in the context of personalised areas for concern and best-practice care pathways to illuminate consultations. We assessed the feasibility of using Spotlight in routine care.

Methods

The Spotlight prototype tool was trialled at three centres (two primary care, one specialist) between June-September 2020.

Results

Thirty-one adults with T1D (n=13 male; n=18 female) participated in this real-world evidence collection, each identifying two priority concerns. ‘Psychological burden of diabetes’ was the most common primary concern (n=27,87.1%) followed by ‘gaining more skills about particular aspects of diabetes’ (n=19,61.3%), ‘improving support around me’ (n=8,25.8%) and ‘diabetes-related treatment issues’ (n=8,25.8%). Burden of diabetes was widespread as was lack of confidence around self-management. Participants with diabetes-related complications more often prioritised "diabetes related treatment issues" than those without complications. People whose last HbA1c was ≥ 8.6% were more likely to prioritise "gaining more skills" than those whose A1c was ≤ 8.5. Men reported greater psychological burden (92.3%-v-83.3%) whilst women prioritised gaining more skills (66.7%-v-53.9%). Those aged <35 years more often prioritised psychological burden than those ≥35 years (100%-v-82.6%). Gaining more skills was more frequently a priority concern among those with higher duration of diabetes (44% among <10 years vs. 68% among >10 years).

Conclusions

Spotlight is acceptable and feasible used in routine care. It is effective in identifying biomedical and psychological priorites of patients.

Background and Aims

Continuous glucose monitoring (CGM) can improve glycemic control for adults with T1D; near-daily use increases benefits. Barriers to consistent use include cost; data overload; alarm fatigue; physical discomfort; and unwanted social attention. This pilot study aimed to examine 1) acceptability of a behavioral intervention, ONBOARD, to support adults with T1D in optimizing CGM use and 2) preliminary effects on diabetes distress and glycemic outcomes.

Methods

Adults (18-50) with T1D in their first year of CGM use were invited to participate in an individualized multicomponent intervention delivered by a psychologist via videoconference over four 60-minute sessions. ONBOARD combines social learning, problem-solving, and education. Participants completed surveys (diabetes distress; satisfaction with program) and provided CGM data at baseline and post-intervention (3 months). Data were analyzed using paired t-tests and Wilcoxon signed-rank tests.

Results

Twenty-two participants (Age=30.95±8.32; 59% female; 91% Non-Hispanic; 86% White, 5% Black, 9% other; 73% pump users) completed the study. ONBOARD demonstrated acceptability: 100% of those who attended 1 session completed all 4 sessions. Most (81%) completers rated ONBOARD as “helpful” or “very helpful”. Moderate effect sizes (Cohen's d and r) were found for diabetes distress and daytime spent in range.

Conclusions

Findings show preliminary evidence that ONBOARD has the potential to optimize CGM use while alleviating diabetes distress. Further research should examine ONBOARD in a larger sample over a longer time period.

Background and Aims

It is currently unknown how much time users spend interacting with hybrid closed-loop systems. We aimed to investigate usage patterns of the CamAPS FX closed-loop app across different populations with type 1 diabetes (T1D).

Methods

We noted average time spent within the CamAPS FX app per day over an 11-week observation period in 134 individuals with T1D from six ongoing clinical studies. The studies included caregivers of very young children (1-7y) with T1D, children and adolescents (6-19y), adolescents (10-17y) using closed-loop from diagnosis, adults, pregnant women, and older adults (≥60y).

Results

The adjusted mean time spent in-app across all user cohorts was 36 minutes/day. This includes initiation of insulin boluses, responding to glucose/system alerts, announcing exercise and reviewing data. Overnight usage was low with 3 minutes on average spent in app. Participants from different demographic cohorts differed significantly in the amount of time spent in-app, ranging from 10 to 81 minutes/day. Pregnant women spent double the time in-app than non-pregnant adults (32 [IQR 25-40] minutes/day vs 16 [IQR 14-18] minutes/day). Adolescents using closed-loop from diagnosis spent the least amount of time engaging with the app (10 [IQR 9-11] minutes/day), while children and adolescents with established T1D had similar engagement time as adults (16 [IQR 13-21] minutes/day). Caregivers of very young children and older adults had the greatest app usage (81 [IQR 63-96] minutes/day and 63 [IQR 39-83] minutes/day respectively).

Figure 1: CamAPS FX app user engagement across six closed-loop studies.

Conclusions

Different user cohorts demonstrate considerable disparities in usage of a closed-loop application.

Background and Aims

As advanced hybrid closed-loop systems come to market, the impact of early adopters on real-world glycemic outcomes is debated. We retrospectively explored glycemic trends in T1D users based on their time of adoption of the Tandem Diabetes Care® t:slim X2™ insulin pump with Control-IQ® technology.

Methods

Participants (N=6,233) included T1D users from Tandem’s installed base who had initiated Control-IQ technology between its launch (January 15, 2020) and July 15, 2020. Participants were divided into three groups based on their time of adoption: within 4 weeks (Group A), between 3-4 months (Group B) and 5-6 months (Group C). Glycemic data was retrieved from Tandem’s t:connect® web application for six weeks pre and post use of the system. Pre-post differences were analyzed using T-test or Wilcoxon-signed rank tests.

Results

Compared to other groups, Group A, initiated Control-IQ technology with a significantly higher median time in range (TIR) (64.1%), lower mean sensor glucose (SG) (167 ±30), and more time with SG<70mg/dL (1.1%). After six weeks of Control-IQ technology, all three groups showed significant improvements in TIR, reductions in mean SG, and time with SG>180mg/dL. Groups B and C demonstrated greater increases in TIR (+11%) vs. Group A (+9.4%).

Conclusions

Irrespective of when Control-IQ technology was adopted, significant improvements in TIR were experienced by all groups. These findings also suggest that early adopters of diabetes technology pursue tighter SG control compared to other users. Further exploration of diabetes management behaviors of early adopters of diabetes technology is recommended.

Background and Aims

This review aimed for the first time to identify and summarize real-world evidence on the extent of suboptimal insulin use in People with Diabetes (PwD).

Methods

A systematic literature search of MEDLINE, EMBASE, and Cochrane databases identified studies reporting data on missed, incorrect, miscalculated, and mistimed insulin doses, and over/underdosing in PwD.

Results

From 3,305 publications, forty records (34 studies) were included. Seventy percent of publications were cross-sectional surveys (n=28). Publications provided data on missed (n=29) and mistimed doses (n=14), over/underdosing (n=9), and dose miscalculations (n=6). PwD reported missing basal and bolus insulin doses in all studies. Eleven records reported glycemic control was better in PwD who did not miss doses. Mistiming of insulin was reported in 14 records, with 20–45% of PwD mistiming doses. Eight records reported mistiming was associated with higher rates of hypoglycemia and/or worse glycemic control. Insulin over/underdosing varied widely across studies. Data were limited regarding dosing miscalculations, but all studies indicated that PwD experienced difficulties with insulin adjustments. Reasons for suboptimal use (n=19 records) were multifactorial, including disrupted daily routines, social situations, and hypoglycemia avoidance. Most dosing errors were unintentional.

Conclusions

Suboptimal insulin use is experienced by almost half of PwDs. This can increase the rate of hyperglycemia and hypoglycemia and is often related to social situations for hypoglycemia avoidance. Technology solutions addressing this could potentially improve diabetes management in most individuals who are actively trying to improve their metabolic control. Studies using artificial intelligence decision support systems and connected insulin pen platforms are warranted.

Background and Aims

Sexuality affects quality of life. The higher prevalence of sexual dysfunction in men with DM can be partially explained by cardiovascular risk factors. Depression is positively associated with sexual dysfunction in both men and women with diabetes. This study aims to report the prevalence of sexual dysfunctions in patients with type 1 and type 2 diabetes (T1D and T2D) and its associations with various clinical and psychological factors. We also examined the proportion of participants receiving psychological treatment.

Methods

Flemish adults with DM were invited to complete an online survey including questions regarding psychological factors, sexual functioning and healthcare use.

Results

Of the 756 participants included (T1D: M/W: 174/242; T2D: M/W: 237/103), one third reported sexual dysfunction. Women reported decreased desire (T1D: 22%; T2D: 15%) and decreased arousal (T1D: 9%; T2D: 11%), while men experienced erectile dysfunction (T1D:20%; T2D; 33%) and orgasmic dysfunction (T1D: 22%; T2D:27%). In men, higher waist circumference (B:=0.063;OR=1.07;p=0.004) and longer duration of diabetes (B=0.034;OR=1.03;p=0.011) were associated independently with sexual dysfunction. Women with sexual dysfunction reported more diabetes distress (36% vs. 21%, p=0.003), impaired well-being (36% vs. 25%, p=0.036), and more anxiety (20% vs. 11%, p=0.026) than without sexual dysfunction. This was more pronounced in T1D (well-being: 39% vs. 26% (p=0.213); diabetes-distress: 39% vs. 26% (p=0.213); anxiety symptoms 22% vs. 15% (p=0.427), T1D and T2D respectively). Women with sexual dysfunction reported more psychological treatment (15 vs. 5%;p=0.002).

Conclusions

Sexual dysfunction is common in men and women with T1D and T2D. Both men and women with sexual dysfunction reported greater diabetes-related distress.

Background and Aims

Incorrect injection technique can cause lipohypertrophy resulting in unpredictable insulin release. We aimed to assess the impact of a correct injection technique and lipohypertrophy on HbA1c, hypoglycemia and glucose variability.

Methods

171 insulin-injecting people with diabetes were prospectively evaluated for 6 months. 146 subjects completed the study (75 type 1, 71 type 2). They were provided extensive education concerning injection technique via an online education platform (BD and Me™) based on the international Forum for Injection Technique & Therapy Recommendations, encouraged to systematically use 4 mm needles and not reuse needles. Primary outcome parameter was the evolution between baseline and end-of-study percentage of needle re-use and injecting in a zone of lipohypertrophy versus glucometrics (HbA1c, hypoglycemia and glucose variability).

Results

At baseline, lipohypertrophy was present in 64%, 51% of patients injected in zones of lipohypertrophy, 37% rotated incorrectly and 96% reused needles. After the intervention, only 8% injected in a lipohypertrophy zone, 4% rotated incorrectly, and 21% reused needles. There was a significant reduction in severe hypoglycemia (from 15.8% to 4.1%, p<0.001), number of unexplained hypoglycemias (from 47% to 16%, p<0.001), and in the number of people with high glucose variability (from 64% to 30% p<0.001). HbA1c (7.5±1.2%) and total daily insulin dose (62±41 units) remained unchanged.

Conclusions

Online education on injection techniques focusing on avoidance of lipohypertrophy zones and reduction of needle re-use results in a significant reduction in severe hypoglycemic episodes, unexplained hypoglycemias and in the number of people with high glucose variability.

Background and Aims

As new and emerging devices are increasingly used for pediatric diabetes care, school nurses need knowledge and confidence to assist students with devices. The aim of this study was to measure school nurse confidence with devices in relation to diabetes knowledge, which, to our knowledge, has not previously been evaluated.

Methods

School nurses in Pennsylvania were recruited to complete a questionnaire evaluating confidence, designed by our group and demonstrating content validity, and the Diabetes Knowledge Test (DKT). We analyzed the association between confidence and prior training, practical experience, and DKT performance using non-parametric tests.

Results

Respondents (n=269) were 99% female, 96% white, mean age 52 years. Most had experience with insulin pumps (95%) and continuous glucose monitor (CGM, 92%), but not sensor-augmented pumps (34%). Half (54%) had cared for 5 or more children with devices in the past 5 years. One-third (37%) of school nurses had received formal device training from a diabetes center. Median response for pump items was 3.1/5 and for CGM items 3.5/5, suggesting moderate confidence overall. Mean score on the DKT was 89% (range 57-100). DKT performance was weakly correlated with pump (0.10, p=0.1) or CGM (0.14, p=0.02) confidence. In contrast, prior training from a diabetes center (pumps p=0.001, CGM p=0.006) and caring for at least 5 students with devices (pumps p=0.004, CGM p=0.004) were associated with higher median confidence.

Conclusions

General diabetes knowledge is not strongly associated with device confidence. Experiential training focused on specific skills may be needed to ensure school nurses are prepared to assist students.