Insulin Omission Research Articles

Assessment of Clinical Profile, And Treatment Outcome of Diabetic Ketoacidosis among Diabetic Children, In Two Selected Hospital, Addis Ababa, Ethiopia, 2020

Background: Diabetic ketoacidosis (DKA) is an acute and life-threatening situation that accounts for the majority of diabetes related morbidity and mortality in children and adolescents who suffer from type 1 diabetes mellitus (T1DM). Diabetic ketoacidosis is the most severe endocrine emergency in pediatrics, which is characterized by hyperglycemia (>250 mg/dl or 14 moll/l), metabolic acidosis (venous pH < 7.3), with associated glucosuria, ketonuria, and ketonemia. Objective: To assess the precipitating factors, clinical presentation, and treatment outcome of diabetic ketoacidosis among diabetic patients in two tertiary hospital of Addis Ababa. Methods: A retrospective analysis was done on the case records of 175 children with diabetic ketoacidosis admitted to our hospital from January 2015 to April 2020. They were managed using a standard protocol including intravenous fluids and insulin infusion. Blood glucose, serum electrolytes, blood urea, and urinary ketones were monitored at regular intervals. The outcomes were assessed. The data was checked for its ’ completeness and entered into Epi version 4.6, and imported to SPSS version 25 software for analysis. The Associations between independent and dependent variables were analyzed using binary logistic regression models. Result: The median age at presentation was 8 years ’ ranges from < 6 months to ≤ 12 years with male to female ratio of 1:1.5. One hundred thirtyseven children (78.3%) were detected to have diabetes mellitus at the time of presentation. Dehydration, Polyuria with polydipsia was the commonest clinical presentation. The precipitating factor of DKA was newly diagnosed, omission of insulin and infection respectively (137, 78.3%, 33, 21.7% and 5,2.9%). There was mortality which accounts 6.9%. Conclusion and Recommendation: DKA were most prevalent in newly diagnosed TIDM cases. Newly diagnosed T1DM and insulin omission were the main factors associated with DKA. The age of presentation and clinical symptoms of studied subjects were similar to international studies. High frequency of DKA at presentation of T1DM requires careful attention to issues of early diagnosis before development of ketoacidosis and subsequently need prevention of DKA management complication. We recommend all the health facilities to give health education about the sign and symptoms of DM and the acute complications of DM.

Healthcare professional awareness of eating disorders in people with type 1 diabetes: a staff survey

Background: People with type 1 diabetes are at increased risk of eating disorders. ‘Diabulimia’, ‘Syndrome of Insulin Omission’ and ‘Type 1 diabetes and Disordered Eating’ (T1DE) are all terms used to describe the omission or restriction of insulin in type 1 diabetes for fear of weight gain. For consistency, Type 1 diabetes and Disordered Eating (T1DE) is used throughout this article. The condition is associated with a significant increase in morbidity and mortality but is not yet recognised as a unique entity.Aim: To determine healthcare professional awareness and knowledge of eating disorders in type 1 diabetes.Methods: A short, cross-sectional, online healthcare professional survey across primary, secondary and community settings.Results: Healthcare professional confidence is low when it comes to recognising and supporting people with T1DE, but there is an interest in learning more.Conclusion: The findings from this study support strategies to improve healthcare professional awareness of T1DE.

A new look at brittle diabetes.

“Brittle diabetes” was first used to describe a life “disrupted by episodes of hypoglycemia or hyperglycemia.” Early descriptions focused on small case reports of mostly young women with psycho-social instability, recurrent diabetic ketoacidosis, poor patient compliance or maladaptation. We redefine “brittle diabetes” as occurring in four specific life stages each with distinct characteristics and associated conditions resulting in severely erratic glycemic control and poor outcomes. Once identified however these factors can often be reversed or significantly mitigated.The first group includes younger patients with associated psychiatric diseases such as bulimia and depression which require specific therapy and are treatable. A second group includes individuals who have another underlying medical condition resulting in disruption of insulin sensitivity or glucose utilization which must be sought. A third group, the largest we believe, has “geriatric type 1 diabetes” and develops severe glycemic instability due to frailty, chronic renal failure, dementia, vision loss, loss of counterregulation and other diseases of aging which lead to unintentional omission of insulin, insulin dosing errors and increasing insulin sensitivity. The fourth group, now seen around the world, suffers lack of insulin access and associated food insecurity. All four of these groups are described.

MON-665 Hypothalamic Gliosis in Adolescents with Type 1 Diabetes and Disordered Eating Behaviors

Background:The hypothalamus and brainstem are thought to be the principal homeostatic brain areas responsible for regulating appetite and weight. Research suggests that inflammation plays a role in the onset and maintenance of eating-related maladaptive behaviors. Hypothalamic inflammation and reactive gliosis mediate disruptions in energy homeostasis, especially with obesity. Data from SEARCH in Youth for Diabetes has demonstrated high prevalence of disordered eating behaviors (DEB) including insulin omission and binge eating, in individuals with type 1 diabetes (T1D). Limited studies have used neuroimaging techniques for investigation of hypothalamic gliosis in individuals with T1D and DEB. Objectives: To determine the feasibility of assessing hypothalamic gliosis with structural MRI in adolescents with T1D with and without DEB.Research design and methods:Adolescents with T1D, aged 13-19, were invited to participate. Participants with current use of medications known to alter appetite were excluded. Participants completed the Diabetes Eating Problem Survey – Revised (DEPS-R). A score ≥ 20 was considered indicative of DEB. Height, weight and waist circumference were obtained, and BMI was calculated. HbA1C was obtained from their prior clinic visit, within 2 months of the study visit. Participants came in fasting for the MRI study visit. Basal insulin (glargine) was administered the night before, and participants on insulin infusion continued with their basal insulin infusion. Participants received rapid-acting insulin prior to the MRI study, and blood glucose was measured before and after the MRI. Mediobasal hypothalamic (MBH) gliosis was measured by T2 relaxation time.Results:Eight subjects (50% female, mean age 17.8±2.3 years) have completed the study without adverse outcomes. Mean HbA1c was 8.5% (range 7.3-10%). Five subjects screened positive for DEB. There was no significant difference in BMI between DEB and non-DEB groups. In this cohort, females had longer T2 relaxation times in left MBH than males (p=0.035). Compared to non-DEB group, participants with DEB had longer T2 relaxation time in left MBH, adjusted for sex and age (p=0.001). In this initial sample, relationships between MBH T2 relaxation times and glycemic control, BMI or waist circumference did not emerge.Conclusion:The study protocol with insulin injection and MRI to study the hypothalamic gliosis in individuals with T1D is feasible. Structural MRI indicated increased T2 relaxation times as a marker of hypothalamic gliosis in participants with DEB. Further studies with larger sample size are crucial to validate these findings and to study specific eating behaviors and their associations with MBH gliosis in individuals with T1D.

Insulin-induced edema in a pediatric patient - clinical case

Introduction: Insulin edema is a rare condition associated with improved glycemic control shortly after diabetes diagnosis or following a period of insulin omission. Clinical findings range from mild edema to severe heart failure and pleural effusion. Diagnosis is clinical and other edema causes should be excluded. Since it is a self-limited condition, there is no need to modify insulin regimen. In more severe cases, diuretic therapy may be required.Clinical case: A 14-year-old female was brought to the Emergency Department due to weight gain and leg swelling with three days of evolution. She had been diagnosed with type 1 diabetes at the age of nine. The girl had poor metabolic control which led to multiple hospitalizations, the last one occurring the week before with a glycated hemoglobin higher than 15%. In physical examination, lower limb edema and a 7-kg weight gain were noted. No jugular vein distension, hepatomegaly, or other forms of edema were found. The girl was hemodynamically stable, with diuresis within the normal range. Analytical study consisting of hemogram, ionogram (sodium and potassium), and renal and hepatic function was normal. Urine analysis revealed glycosuria and chest x-ray showed no abnormalities. The diagnosis of insulin-induced edema was established and water and saline restriction recommended, with total symptom resolution three weeks later.Conclusion: Despite rare, clinicians should be aware of this condition, as most cases do not require modifying the insulin regimen.

Management of diabetic ketoacidosis after the introduction of local hospital protocol in the secondary care hospital

Background: Diabetic ketoacidosis (DKA) is an acute, severe and life-threatening metabolic complication of diabetes. Objective: The objective of this study was to conduct a clinical audit of the management of DKA based on the hospital protocol in the selected secondary care hospital. Design: An observational retrospective longitudinal study design was used to review the data of the patients admitted with DKA. Settings: The study was conducted in a secondary care government hospital, which has 200 beds, including 48 beds in medical ward and 6 beds in the high dependency unit. Materials and Methods: A survey questionnaire was used based on local hospital protocol, and the data was collected from patients admission notes between January 2010 and December 2014, using electronic patients records. Outcome Measures: The study looked at outcomes such as how DKA protocol was followed, complications, adherence, causes, investigations carried out or not, severity, readmissions, and duration of the stay. Sample Size: The audit selected 49 patients from a total of 83 admission notes with DKA who fits the sampling criteria. Results: Of 49 patients, 38 patients were having type 1 diabetes mellitus and 11 patients having type 2 diabetes mellitus. The most common cause in both groups is omission of insulin. Intravenous 0.9% sodium chloride was initiated in the early first hour of diagnosis of DKA for most patients. Readmission rate was 25%. Insulin was commenced in less than 1h for two-thirds of the total patients. Poor adherence to the protocol such as monitoring serum sodium bicarbonate, serum potassium levels and replacement of potassium levels in the early period of management were observed. Conclusion: Continued evidence-based practice and education for medical and paramedical staffs is needed to reduce the complications of DKA and efficiently resolve DKA, improve patient outcomes, and reduce the length of hospital stay. New DKA protocol has been introduced in the hospital as the result of this audit.

Clinical Profile of Diabetic Ketoacidosis among Children in Eastern Nepal

Background: Diabetic ketoacidosis (DKA) is a life threatening complication which is the most common reason for hospital admission in children with Type 1 Diabetes. This study was carried out to determine the clinical characteristics of children admitted with Diabetic Ketoacidosis.&#x0D; Methods: Descriptive retrospective study was conducted at B.P. Koirala Institute of Health Sciences (BPKIHS), Dharan, Nepal. A total of 25 children of less than 20 years old diagnosed with Diabetic ketoacidosis who were admitted to the pediatric ward and pediatric intensive care unit from January 2013 to December 2017 were included in the study. Data were collected via hospital records of patients.&#x0D; Results: The mean age at presentation was 10.5 ± 4.5 years. Sixteen (64%) children were newly diagnosed as diabetes while, nine (36%) children were known cases of diabetes. The most common precipitating factor for DKA was omission of insulin 6 (24%). Twelve (48%) children had presented with severe DKA. Polyuria 23 (92%) was the commonest symptom followed by polydipsia 22 (88%), weight loss 17 (68%), abdominal pain 13 (52%), vomiting 13 (52%) and unconsciousness 8 (32%). The mean duration of symptoms before presentation was 11.3 ± 5.7 days. Mean HbA1c at presentation was 10.4 ± 2.2.&#x0D; Conclusion: Majority of the patients was newly diagnosed as diabetes who presented with Diabetic ketoacidosis. Omission of insulin was the main precipitating factor. Polyuria was the most common presenting symptom. Proper follow up care of diabetes and community awareness programs should be emphasized to reduce the incidence of Diabetic ketoacidosis.

Type 2 diabetes care: Improvement by standardization at a diabetes rehabilitation clinic. An observational report.

BackgroundOutcome of type 2 diabetes care depends on the acceptance of self-responsibility by informed patients, as treatment goals will otherwise be missed.Aims and methodsThis pre/post-observational report describes the clinical outcome of type 2 diabetes care in patients with type 2 diabetes (N =930) admitted consecutively to a diabetes rehabilitation clinic (DRC) between June 2013, and June 2016, where they were exposed to standardized lifestyle modification with meals low in salt and rich in vegetables and fruits, totaling 1,200 to 1,600 kcal/d, and an add-on exercise load equivalent to 400–600 kcal/d.ResultsAt admission, patients presented with multiple treatment modes, elevated HbA1c levels (7.6±1.5%, 60±16 mmol/mol), a high prevalence of co-morbidities dominated by obesity (79%), a low rate of influenza and pneumococcal immunization (<9%) and underuse of lipid-lowering drugs (-29%). Analysis of clinical and metabolic outcome after 3 weeks shows that simple standardization of and better adherence to treatment recommendations improved (p<0.0001) glucose (HbA1c -0.4±0.4%) and lipid metabolism (LDL/HDL ratio, -0.58±0.03), permitting a 39% reduction in insulin dosage, omission of insulin in 36/232 patients and omission of oral antidiabetic drugs (OADs) other than metformin and DPP4-inhibitors, while the use of GLP-1 analogs doubled to 5.2%. Improved outcome was independent of treatment strategy and more marked at initially high HbA1c at costs less than 25% of those encountered at a standard hospital.ConclusionsOur observations support the clinical notion that adherence to basic treatment recommendations is indispensable in type 2 diabetes care if metabolic and clinical treatment goals are to be met, and if inappropriate add-on over-medicalization with OADs and/or insulin is to be avoided. To this end, ‘imprinting’ patients at a DRC could be of considerable help.

Disturbed Eating Behaviors in Adolescents and Emerging Adults With Type 1 Diabetes: A One-Year Prospective Study.

Disturbed eating behavior (DEB) is prevalent in youth with type 1 diabetes and is accompanied by an increased risk for complications, morbidity, and mortality. Prospective studies on DEB in the challenging transition to adulthood are scarce. This longitudinal study examined DEB over a 1-year period and investigated the directionality of effects linking DEB to diabetes-specific functioning and depressive symptoms in adolescents and emerging adults. Three hundred youth (16-28 years old) with type 1 diabetes participated in a two-wave longitudinal study. Questionnaires measured DEB (Diabetes Eating Problem Survey-Revised [DEPS-R]), self-management, diabetes distress, and depressive symptoms. HbA1c values were obtained from physicians. Mixed ANOVA and cross-lagged analysis were used to examine prospective changes and directionality of effects, respectively. Mean DEB remained stable in the total sample, but significant individual differences were observed based on the cutoff score of the DEPS-R: 19% displayed persistent DEB and 8% increased and 7.3% decreased in DEB over time. The remaining individuals scored low on DEB over time. These four groups were differentiated based on insulin restriction, omission, diabetes-specific functioning, and depressive symptoms. Cross-lagged analyses indicated that DEB predicted relative increases in depressive symptoms over time, whereas reciprocal associations with glycemic control were found. This longitudinal study highlights the substantial impact DEB may have in the transition to adulthood, with a substantial portion of youth with type 1 diabetes being at risk for clinical DEB. Prospective pathways linking DEB to functioning were found, emphasizing the clinical relevance of assessing DEB over time.

207-OR: Intentional Insulin Omission for Weight Loss and Psychosocial Outcomes among Youth with Type 1 Diabetes: Findings from Routine Screening

Introduction: Research has found that up to 31% of youth with type 1 diabetes (T1D) restrict insulin in efforts to lose weight (Wisting et al., 2013), and that restricting or omitting insulin has been linked to higher HbA1c. However, less is known about psychosocial outcomes among youth who omit insulin. The purpose of the current study was to examine associations between intentional omission of insulin to lose or avoid gaining weight and psychosocial outcomes among youth with T1D. Methods: Participants included 54 youth with T1D ages 12-17 (M age = 14.7, 55.6% female) and their caregivers, recruited during routine diabetes clinic visits. Youth and caregivers completed an annual psychosocial screening battery which included the PROMIS® depression and anxiety scales, the Problem Areas in Diabetes measure, and the Diabetes Family Conflict Scale. Youth also answered questions on their intentional omission of insulin to either lose or avoid gaining weight. Analyses were conducted via Pearson’s correlations, t-tests, and Chi-square tests. Results: Intentional omission of insulin to lose or avoid gaining weight was significantly positively correlated with youth-report of depression, anxiety, diabetes distress, and diabetes-related family conflict. Compared to youth who do not intentionally omit insulin, those who do omit insulin were more likely to have clinically elevated levels of depression (p’s &amp;lt; .05). No differences for parent-reported psychosocial outcomes were found. Conclusions: Results reveal that youth who intentionally omit insulin for weight purposes are at risk for poorer psychosocial outcomes, especially depression. Additional research is needed to understand the causal direction of these associations, and to examine the potential role of disordered eating behavior. Results also highlight how psychosocial screening during routine diabetes visits can identify youth and caregivers in need of behavioral health interventions. Disclosure J.L. Papadakis: None. L.M. Anderson: None. A.T. Vesco: None. M.A. Evans: None. J. Weissberg-Benchell: Consultant; Self; Roche Diabetes Care.

887-P: Biological and Psychological Risk Factors for Eating Disorders in Type 1 Diabetes

Background: Women with type 1 diabetes (T1D) are 2.4 times more likely to develop an eating disorder than their nondiabetic peers. In addition, T1D has been reported as a risk factor associated with the development of an eating disorder. Objective: To identify the biological disruptions and psychological pressures unique to a person with T1D that create a higher risk for developing an eating disorder. Design and Methods: Conducted a three-year review of literature, articles and research studies on biological systems impacted by T1D, and on the psychological factors involved in eating disorders. Merged the research with case-study evidence obtained from Diabulimia Helpline clients and online support group members through discussions, posts and responses to questions. Results: A number of physiological consequences of the destruction or removal of beta cells are known precursors to the onset of an eating disorder. Insulin is required for proper regulation of leptin, neuropeptide Y and dopamine, all of which are involved in the consumption and use of energy. While insulin analogs have made great strides, they do not perfectly mimic natural insulin or it’s interactions with other hormones and neurochemicals in the body. In addition, the more “out of range” a person’s blood glucose is, the more disrupted are these physiological mechanisms. The absence of amylin disrupts satiety mechanisms both directly in the brain and indirectly in the intestine through uncontrolled gastric emptying. In addition, certain character traits that are associated with eating disorders, such as avoiding thoughts and emotions or black and white thinking, can be exacerbated with a T1D diagnosis. Conclusion: The development of T1D increases the number of risk factors a person has for developing an eating disorder, some of which are biological in nature and thus cannot be avoided. We can also see how biology becomes psychology when, for example, a reduction of leptin creates a risk of binging which in turn creates a risk for insulin omission. Disclosure D. Lee-Akers: None. J. Simon: None. E. Akers: None.

Precipitating Factors, Clinical Features and Outcome of Diabetic Ketoacidosis in Children in a Tertiary Care Hospital of Bangladesh

Background: Diabetic ketoacidosis (DKA) is a major complication of type 1 and type 2 diabetes mellitus and is associated with increased risk of morbidity and mortality. Infections, non-compliance and co-morbid states are most important precipitating causes. Proper identification of the precipitating factor is very important in management of DKA. Clinical feature and management of DKA are well known and have been described in many text books and reviews in literature. However, there are a very few published large studies from Bangladesh. For this reason, this study had evaluated fifty children with Diabetic ketoacidosis and to identify their clinical features, precipitating factors and outcome.&#x0D; Methods: This observational study was done among admitted children with DKA in the deptartment of Paediatrics of Bangladesh Institute of Research and Rehabilitation for Diabetes, Endocrine and Metabolic Disorders (BIRDEM) General Hospital during study period between September 2016 to February 2017.&#x0D; Results: Fifty children were admitted with Diabetic ketoacidosis. Seventy percent were new diabetes cases and the remaining (30%) were known diabetic patient. Majority (62%) were female. Mean age was 9.31 years with 4.40 standard deviation. Infection was the commonest (62%) precipitating factor followed by insulin omission (10%). Major clinical features were dehydration (100%), polyuria (98%), Kussmaul’s breathing (60%) and abdominal pain (38%). Eighty four percent patients improved after treatment and 16% patient developed complications like acute kidney injury and septicaemia. There was no mortality.&#x0D; Conclusion: Infection was the commonest precipitating factor of DKA. Kussmaul’s breathing and dehydration were the commonest clinical features. Most of the patients improved after treatment&#x0D; Birdem Med J 2019; 9(2): 121-126

SUN-LB048 Takayasu Arteritis in a Young Woman with Type 1 Diabetes

Takayasu arteritis (TAK) is a rare, chronic large-vessel vasculitis affecting primarily the aorta and its branches. It is uncommon in children and non-Asian ethnic groups. Co-incidence of TAK and type 1 diabetes (T1DM) is rare. We present a case of a 19-year-old Hispanic woman with longstanding T1DM and autoimmune thyroiditis who was diagnosed with TAK. She presented with T1DM and subclinical autoimmune thyroiditis at age 9. She was poorly adherent to diabetes care plan and admitted multiple times for DKA due to insulin omission. HbA1C average over 10 yrs was approximately 11%. At age 18 she presented to an outside hospital with severe abdominal pain and was diagnosed with appendicitis. Appendectomy was complicated by identification of an ischemic segment of small bowel, which was resected, and also for finding a thrombosis in the superior mesenteric artery (SMA). The SMA thrombosis was initially felt to be related to the prothrombotic state of poorly controlled DM1; she had a high atypical p-ANCA titer but erythrocyte sedimentation rate (ESR) had been normal. Her clinical course was complicated by severe cachexia resulting in multiple readmissions to address chronic abdominal complaints, malnutrition and diarrhea. She was also admitted for an episode of pyelonephritis during which she developed severe liver dysfunction of unclear cause. Diabetes remained poorly controlled. At age 19 she was admitted for DKA and weight loss. An abdominal bruit was identified on exam. There was no hypertension. Labs demonstrated a significant elevation of ESR of 101 mm/hr. A diagnostic evaluation was initiated. Imaging (CT and MR angiography) revealed chronic occlusion of the proximal SMA as well as vasculitis of the infrarenal aorta and inferior mesenteric artery. Conventional angiogram did not show vasculitis distal to the origin of the aortic vessels. Based on the constellation of findings including constitutional and gastrointestinal symptoms, the arterial bruit on exam, the high ESR, and findings on imaging, a diagnosis of large-vessel vasculitis (TAK) was made. She was treated with azathioprine and a taper of oral prednisone. Weight increased and ESR decreased initially down to 20 mm/hr, but ESR again increased (up to 40 mm/hr) with imaging evidence of ongoing vasculitis when steroids were weaned. This case adds to the sparse literature describing the association between TAK and T1DM. It highlights that TAK may occur in very young adults of non-Asian descent. It also showcases the difficulty in diagnosis of TAK, which may have a subacute and nonspecific presentation, in an individual with poorly controlled DM1 as well as SMA thrombosis, which has been described as an acute complication of DKA in case reports. The use of systemic glucocorticoids as a mainstay of TAK therapy may present additional challenges in an individual with DM1. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. s presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

Clinical characteristics and outcomes of care in adult patients with diabetic ketoacidosis: A retrospective study from a tertiary diabetes center in Thailand

BackgroundDiabetic ketoacidosis (DKA) is a metabolic catastrophe which could occur in any type of diabetes. Even when fundamental key points of DKA treatment had been followed, some differences exist in treatment protocols in each physician, highlighting the need to assess adherence to DKA guideline. AimThis study aimed to examine trend of hospitalized DKA patients and outcomes of treatment over a decade at Theptarin Hospital, a multi-discipline based diabetes center in Thailand. MethodA retrospective study of DKA episodes admitted over a 14-year period (2005–2018) was done. Clinical characteristics, laboratory data, type of diabetes, severity of DKA were collected and analyzed. ResultsA total of 94 DKA episodes occurred in 81 diabetic patients (females 61.5%, mean age 47.4 ± 20.4 years, T1DM 41.5%, T2DM 50.0%, Ketosis-prone diabetes 8.5%, baseline A1C 10.8 ± 3.0%). While infection was the common precipitating factor in T2DM, omission of insulin was the usual precipitating factor in T1DM. During ongoing management, 26.6% of patients developed hypokalemia and supplementation was not prescribed as per protocol in this group of patients. Almost 13% of patients experienced hypoglycemia in the first 24 h. Median time to resolution of DKA was 8.5 h. Four T2DM patients expired from the precipitating cause of DKA which accounted for mortality rate at 4.3% in our study. ConclusionsInadequate metabolic monitoring and iatrogenic hypoglycemia remain areas of concern for DKA management. Occurrence of hypokalemia was related to poor adherence to protocol guidance on potassium supplementation. A strengthened educational program for nursing and medical staffs should be emphasized.

Factors Associated with Insulin Nonadherence in Type 1 Diabetes Mellitus Patients in Mexico

Background: Lack of adherence to insulin therapy is common among patients with type 1 diabetes. Factors associated with insulin omission in adult persons with type 1 diabetes in Latin America have not been studied in detail. Objectives: To investigate factors associated with insulin nonadherence including the presence of psychological disorders (disordered eating behaviors and depression) in adult patients with type 1 diabetes. Methods: Cross-sectional study including 104 consecutive adults (≥18 years old) attending a tertiary care center in Mexico City. Adherence to insulin therapy was measured with a specific item in a questionnaire. Sociodemographic data and factors related to insulin omission, including validated questionnaires to evaluate disordered eating behavior and depression, were collected and compared between the nonadherent and adherent groups with parametric or nonparametric statistical tests, as appropriate. Results: We classified 51 (49.1%) patients as nonadherent and 53 (50.9%) as adherent. Adherent subjects reported that they planned their activities around insulin application more often than the nonadherent subjects did (43.4 vs. 23.5%, p = 0.032). In a logistic regression model, fear of hypoglycemia (OR = 11.39) and economic reasons (OR = 6.02) were independently associated with insulin adherence. Presence of disordered eating behavior was identified in 14.4% of subjects, the majority belonging to the nonadherent group. Conclusions: Only 50% of the patients with type 1 diabetes were adherent. The principal factors associated with nonadherence were economic reasons and fear of hypoglycemia.

Audit of insulin prescription patterns and associated burden among diabetics in a tertiary health institution in Nigeria.

Insulin is one of the most important anti-diabetic agents in the management of diabetes even among type 2 diabetic. There was need to assess insulin adherence, mode of insulin delivery and burden of insulin usage among diabetics. A cross-sectional, prospective questionnaire, orally administered at a Diabetes Clinic of a University Teaching Hospital, SouthWest, Nigeria. Participants were consecutive patients with diabetes who were 18 years or older presently on insulin either alone or in combination with other anti-diabetic agents for at least 3 months. Baseline demographic and insulin treatment information were obtained. Two hundred and thirteen (213) participants were studied. Of these, 21 (9.9%) had T1DM and 192 (90.1%) had T2DM, (means age, 58.6 ± 13.1 years, mean duration of diabetes, 7.0 ± 6.9 years). Insulin adherence was noted in 72.8% with better adherence among those who self-injected insulin compared to those who were injected by health care professionals (HCPs) or relations. Among the respondents, 80.8% were on human insulin and pre-mixed insulin was the most commonly used form of insulin (52.6%). Most participants (52.6%) were taking 10-20 units per day, only 22 (10.3%) were on >40units/day. Reuse of insulin needle was found in 74.6% of the participants. Major reasons for insulin omission were non-availability of insulin and patients being tired of insulin injection. The insulin adherence among diabetics in this study was high. Non-availability of insulin, insulin injection pain and being tired of continual insulin usage were some of the reasons for non-adherent to insulin usage.

Fasted High-Intensity Interval and Moderate-Intensity Exercise Do Not Lead to Detrimental 24-Hour Blood Glucose Profiles.

To compare the effect of a bout of high-intensity interval training (HIT) with a bout of moderate-intensity continuous training (MICT) on glucose concentrations over the subsequent 24-hour period. Fourteen people with type 1 diabetes [T1D (duration of T1D, 8.2 ± 1.4 years)], all on a basal-bolus regimen, completed a randomized, counterbalanced, crossover study. Continuous glucose monitoring was used to assess glycemic control after a single bout of HIT (six 1-minute intervals) and 30 minutes of MICT on separate days compared with a nonexercise control day (CON). Exercise was undertaken after an overnight fast with omission of short-acting insulin. Capillary blood glucose samples were recorded before and after exercise to assess the acute changes in glycemia during HIT and MICT. There was no difference in the incidence of or percentage of time spent in hypoglycemia, hyperglycemia, or target glucose range over the 24-hour and nocturnal period (12:00 am to 6:00 am) between CON, HIT, and MICT (P > 0.05). Blood glucose concentrations were not significantly (P = 0.49) different from pre-exercise to post-exercise, with HIT (0.39 ± 0.42 mmol/L) or MICT (-0.39 ± 0.66 mmol/L). There was no difference between exercise modes (P = 1.00). HIT or 30 minutes of MICT can be carried out after an overnight fast with no increased risk of hypoglycemia or hyperglycemia. If the pre-exercise glucose concentration is 7 to 14 mmol/L, no additional carbohydrate ingestion is necessary to undertake these exercises. Because HIT is a time-efficient form of exercise, the efficacy and safety of long-term HIT should now be explored.

Insulin Adherence in Type 2 Diabetes in Mexico: Behaviors and Barriers.

Objective To investigate factors associated with insulin adherence in subjects with type 2 diabetes mellitus (T2D) attending a tertiary care centre in Mexico City. Material and Methods Cross-sectional study, including 200 patients. Adherence to insulin therapy was measured with a medication adherence questionnaire. Sociodemographic data and factors related to insulin omission were collected and compared between the nonadherent and adherent groups. Results We categorized 117 (58.5%) patients as nonadherent and 83 (41.5%) as adherent. Among the adherent, only 22 patients (11%) had excellent adherence to insulin therapy. The following factors were associated with nonadherence: lack of planning of daily activities (46.1%), fear of hypoglycemia (41%), economic factors (15.4%), and number of insulin applications (2.31 versus 1.76 applications per day). Conclusions In this study, patients with type 2 diabetes attending a tertiary care referral centre showed inadequate adherence to insulin therapy. The principal factors associated with insulin omission were low socioeconomic status, fear of hypoglycemia, and a greater number of insulin applications per day.

Reasons for Insulin Omission—What Matters Most?

Background: One in 3 people with diabetes (88% with type 2 diabetes [T2D]) do not take insulin as recommended an average ∼3.3 days per month. Insulin omission (IO) is associated with suboptimal A1c. Reasons for IO are multifactorial (e.g., cost, fear, stigma). Unclear are what matters most for reducing IO and improving A1c. Objective: We assessed 10 reasons for IO among a national sample of people with T2D, and identified reasons that, if addressed, might improve A1c. Methods: Adults (age 18-75 years) with T2D self-selected to be in a randomized control trial comparing inhalable, ultra-rapid-acting insulin (Afrezza) with One Drop’s digital therapeutics solution vs. injectable, rapid-acting insulin with One Drop. A HIPAA protected, online survey screened potential participants. Eligible persons completed a baseline survey and NGSP certified A1c test. Survey items collected demographics, reasons for IO, and responses to the ARMS-D and SDSCA-IS to assess IO. We used SPSS v25 for psychometric, descriptive, and multivariate statistics, and PROCESS v3 for unadjusted and adjusted mediation models with bootstrapped (10K) CIs. Results: Participants (N=269) were 50±11 years old, 51% male, 30% non-white, 90% insured, with 13±8 years since a T2D diagnosis, and A1c 8.8%±1.8%. ARMS-D insulin had internal consistency reliability (α=.82), and convergent validity with SDSCA-IS (rho=.46, p&amp;lt;.001). IO was associated with higher A1c (β=.39, p&amp;lt;.001). Cost (coef.=.08; 95% CI:.02-.15), disruption (coef.=.07; 95% CI:.001-.15), fear of side effects (coef.=.15; 95% CI:.07-.26), and burnout (coef.=.11; 95% CI:.05-.19) had indirect effects on higher A1c through IO. Reasons were not directly related to A1c. Discussion: Cost, disruption, fear, and burnout were associated with IO, and higher A1c through IO. Given time and resources constraints, clinic visits and self-care interventions must prioritize and address modifiable factors contributing to both non-adherence and higher A1c. Such efforts may be more effective than other approaches. Disclosure C.Y. Osborn: Employee; Self; One Drop. Research Support; Self; MannKind Corporation. Stock/Shareholder; Self; One Drop. L.E. Sears: Employee; Self; Informed Data Systems Inc.. Research Support; Self; MannKind Corporation. A. Hirsch: Employee; Self; One Drop. Research Support; Self; MannKind Corporation. J. Raymond: None. M. Heyman: Employee; Self; One Drop. R. Head: None. J. Dachis: Stock/Shareholder; Self; One Drop. Board Member; Self; One Drop. Employee; Self; One Drop.

'Diabulima' through the lens of social media: a qualitative review and analysis of online blogs by people with Type 1 diabetes mellitus and eating disorders.

To perform a qualitative review of online blogs authored by people self-identifying as having Type 1 diabetes and an eating disorder or 'diabulimia', a term used by people with Type 1 diabetes to describe an eating disorder that is characterized by deliberate restriction of insulin to control weight. We conducted a structured qualitative review of online blogs published between 2012 and 2017 authored by people who report having Type 1 diabetes and an eating disorder or diabulimia. The subsequent thematic analysis followed a six-phase process and was conducted by two independent researchers. From 147 000 search results, 11 blogs (304 posts) matched criteria for further analyses. Three key themes and 18 subthemes emerged: 1) different aspects of bloggers' relationship with insulin, including motives for omitting insulin, secrecy of insulin omission and perception of control; 2) bloggers' experiences of diabetes complications, and diabetes ketoacidosis in particular, as well as their worries about future complications; 3) strategies for recovery and triggers for relapse, which involved diabetes self-management and setting up a support system. Qualitative analyses of blogs authored by people with Type 1 diabetes and an eating disorder or diabulimia have identified high levels of diabetes distress and provided insight into different motives for insulin omission and strategies for recovery. Considering the limited evidence for effective interventions, these findings may help the development of complex interventions to improve biomedical and psychological outcomes in this group.