Pediatric Type 1 Diabetes Research Articles

Experience of Caring for a Child With Type 1 Diabetes Mellitus in a Food-Insecure Household: A Qualitative Evaluation

ObjectivesAn earlier study from Nova Scotia showed that food insecurity (FI) is more prevalent (21.9%) in families of children with diabetes, yet little is known about its impact on these families. We aimed to describe the day-to-day experiences of families living with FI while caring for a child with type 1 diabetes (T1D). MethodsThis investigation was a qualitative study with thematic analyses using semistructured interviews to explore perceptions of caregivers living with pediatric T1D and FI (N=13 households). ResultsThree major themes emerged: 1) FI had a disproportionate impact on families after T1D diagnosis compared with before diagnosis. The cost of healthy food threatened food security before T1D; however, there is increased hardship once high-quality food and hypoglycemia supplies are required. 2) Sacrifices to combat FI have disproportionate impacts among family members. At times, caregivers sacrificed the needs (food, medicine) of other family members (including children) to prioritize the needs of the child with T1D. 3) Caregivers perceived T1D needs as posing unique barriers to traditional FI supports, such as school breakfast programs. ConclusionsThis study provides insight into the realities of life with pediatric T1D and FI. Living with T1D and FI poses challenges, and caregivers often cope by making difficult choices when providing for their family. Caregivers struggled to meet dietary recommendations while finding that T1D needs are often not met by traditional FI supports. This suggests that T1D clinicians should assess FI and help families in problem solving to mitigate its impact.

Concordance and Discordance in the Geographic Distribution of Childhood Obesity and Pediatric Type 2 Diabetes in New York City.

As rates of childhood obesity and pediatric type 2 diabetes (T2D) increase, a better understanding is needed of how these 2 conditions relate and which subgroups of children are more likely to develop diabetes with and without obesity. To compare hotspots of childhood obesity and pediatric T2D in New York City, we performed geospatial clustering analyses on obesity estimates obtained from surveys of school-aged children and diabetes estimates obtained from health care claims data, from 2009 to 2013. Analyses were performed at the Census tract level. We then used multivariable regression analysis to identify sociodemographic and environmental factors associated with these hotspots. We identified obesity hotspots in Census tracts with a higher proportion of Black or Hispanic residents, with low median household income, or located in a food swamp. Total 51.1% of pediatric T2D hotspots overlapped with obesity hotspots. For pediatric T2D, hotspots were identified in Census tracts with a higher proportion of Black residents and a lower proportion of Hispanic residents. Non-Hispanic Black neighborhoods had a higher probability of being hotspots of both childhood obesity and pediatric T2D. However, we identified a discordance between hotspots of childhood obesity and pediatric diabetes in Hispanic neighborhoods, suggesting either under-detection or under-diagnosis of diabetes, or that obesity may influence diabetes risk differently in these 2 populations. These findings warrant further investigation of the relationship between childhood obesity and pediatric diabetes among different racial and ethnic groups, and may help guide pediatric public health interventions to specific neighborhoods.

Effects of Chronic Artificial Sweetener Consumption on Type 1 Diabetes Susceptibility

As the diabetes epidemic grows worldwide, there is a heightened awareness of how modern day diets may contribute to the increased incidence of disease. To combat the dietary intake of sugar, there has been a drastic increase in the daily consumption of non‐caloric artificial sweeteners (NCAS). However, a number of studies suggest that NCAS cause counterintuitive metabolic derangements that may contribute to negative health outcomes. Conversely, there are limited duration studies focused on weight management suggesting the opposite, thus creating controversy. The impact of chronic NCAS consumption in type 1 diabetes (T1D) patients or those with a high genetic susceptibility for T1D is also unknown. T1D has a strong genetic basis; however, environmental factors likely underlie the rapid increase in T1D incidence in the past few decades. Children with T1D frequently consume NCAS as a way of managing postprandial hyperglycemia and insulin doses. Increased availability of NCAS within the home likely also translates to more NCAS consumption by non‐diabetic siblings with a higher risk to develop T1D. Our study aimed to test the effects of chronic consumption of NCAS subtypes on high T1D susceptibility backgrounds. To test this, we supplemented the diet of T1D susceptible BioBreeding DR+/+ rats with aspartame (metabolized) and acesulfame potassium (Ace‐K+, not metabolized) for three weeks in their drinking water. DR+/+ rats consuming NCAS water had a significant increase in blood glucose versus normal water controls. Metabolomics analysis of plasma from these rats revealed alterations in lipid and energy metabolism, with a greater effect resulting from Ace‐K+. Using a novel mass spectrometry‐based quantification assay we developed, we found that Ace‐K+ also accumulated in the plasma these DR+/+ rats (21+10 μM; N=6) following chronic consumption. Further follow‐up was performed in vitro using rat cardiac microvascular endothelial cells (RCMVECs) to measure cardiometabolic effects. The RCMVECs were treated with an Ace‐K+ dose‐response for three weeks and they exhibited impairment during in vitro tube formation and cell viability tests (p<0.05; N=3). Gene expression analysis of the RCMVECs displayed significant differences in insulin signaling, glucose metabolism, and inflammatory regulation (p<0.05; N=4). In further tests, we also observed that chronic Ace‐K+ consumption accelerated the rate of type 1 diabetes onset in DRlyp/lyp rats. Overall, these results suggest that the accumulation of absorbed intact NCAS subtypes, like Ace‐K+, have the potential to lead to metabolic flux that may be important in pre‐ and post‐onset T1D, whereas the metabolized aspartame caused less fluctuation. We are now focused on translating these studies to a pediatric T1D population and are implementing a novel NCAS food frequency questionnaire and plasma quantification test to better measure consumption clinically.Support or Funding InformationSupport for this project was provided by the Medical College of Wisconsin Clinical and Translational Science Institute, the Mayo Clinic Metabolomics Resource Core (pilot award provided by the U24DK100469 grant to BRH), and the Children’s Research Institute (CRI19301 to MH).

Monitoring of Pediatric Type 1 Diabetes.

Regular self-monitoring of blood glucose levels, and ketones when indicated, is an essential component of type 1 diabetes (T1D) management. Although fingerstick blood glucose monitoring has been the standard of care for decades, ongoing rapid technological developments have resulted in increasingly widespread use of continuous glucose monitoring (CGM). This article reviews recommendations for self-monitoring of glucose and ketones in pediatric T1D with particular emphasis on CGM and factors that impact the accuracy and real-world use of this technology.

The current state of parent feeding behavior, child eating behavior, and nutrition intake in young children with type 1 diabetes.

One integral component of type 1 diabetes (T1D) management is attention to nutrition, which can be particularly challenging in young children. The current study reports on parent and child eating/feeding behavior and nutrition intake as compared with current recommendations for pediatric T1D. Participants were 46 children ages 2 to 5 diagnosed with T1D and one parent. The Behavioral Pediatrics Feeding Assessment Scale (BPFAS) was used to assess parent feeding and child eating behaviors. The Remote Food Photography Method (RFPM) was used to analyze nutrition intake at breakfast. Demographic and medical information were collected via self-report and medical chart review. In the current sample, 37% of BPFAS scores were above the cutoff for problem child eating behavior. Only 28% of participants met the recommended goals for glycemic control (hemoglobin A1c, HbA1c < 7.5). Children who did not meet glycemic control targets reported higher carbohydrate intake than those meeting targets. Protein recommendations were met by 46%; 22.7% met the recommendation for carbohydrate intake, and 45.5% met fat intake recommendations. The majority of the sample did not meet body mass index percentile (BMI%) recommendations with 51% having a BMI% above the 85th percentile. Many parents of young children with T1D report problem child eating behaviors. Further, a significant number of young children are not meeting glycemic, nutritional, or BMI guidelines for T1D. Routine screening for dietary difficulties in young children is warranted. Future research should aim to examine interventions targeting families with young children not meeting nutrition, glycemic, or BMI guidelines.

Rapid progression of type 2 diabetes and related complications in children and young people-A literature review.

Type 2 diabetes (T2D) is suggested to progress faster in children and young people vs type 1 diabetes (T1D) in the same age group and T2D in adults. We reviewed the evidence base for this. A literature search was performed of PubMed‐indexed publications between 2000 and 2018, for the terms “pediatric” and “T2D.” Results were combined and filtered for those relating to “progression.” Searches of abstract books from Latin American and Asian congresses were performed to include these populations. Pediatric populations were defined as <25 completed years of age. Of the articles and congress abstracts found, 30 were deemed relevant. Dividing the studies into categories based on how T2D progresses, we found the following: (a) yearly beta‐cell function deterioration was shown to be 20% to 35% in children with T2D compared with 7% to 11% in adults with T2D, despite similar disease durations; (b) retinopathy progression was likely dependent on diabetes duration rather than diabetes type; however, nephropathy, neuropathy and probably hypertension progressed faster in youth‐onset T2D vs T1D. Nephropathy progression was similar to adults with T2D, allowing for disease duration. Youth with T2D had a worse cardiovascular (CV) risk profile than youth with T1D, and a faster progression to CV death. (c) Progression to treatment failure was faster in youth‐onset T2D vs adult‐onset T2D. Substantial evidence exists for faster progression of T2D in pediatric patients vs T1D or adult‐onset T2D. New treatments targeting the pathology are needed urgently to address this issue.

Pediatric type 1 diabetes research in the 21st century: a scientometric review.

Scientometric studies help scientists to identify research gaps and plan future research. There is no scientometric assessment of research on childhood onset type 1 diabetes (T1D), despite an intensive research in this field over the past 2 decades. To provide a scientometric assessment of global research output in pediatric T1D. Publications on pediatric T1D indexed in Scopus database over the 20-year period from 2000 to 2019 were examined. The most productive and impactful countries, organizations and authors, trends in research, the media of publications and characteristics of high cited publications were identified using appropriate bibliographic tools. Pediatric T1D research registered 7.84% and 79.99% annual and 10-year cumulative growth and averaged 19.35 citations per paper (CPP). The field witnessed an uneven participation of 141 countries, wherein 82.67% of the global research output share came from top 10 countries. USA leads the ranking with 29.76% share, followed by UK (10.56%), Germany, Italy, Sweden and Australia (5.15% to 7.88%), and Poland, Finland, Canada and Denmark (3.04% to 4.24%). Five countries which registered relative citation index (RCI) higher than their group average of 1.63 were Finland (2.30), UK (1.82), Canada (1.77), Denmark and USA (1.74 each). The number of participating organizations and authors was 3627 and 5596 respectively. The USA and Finland are the most productive and the most impactful countries respectively in global pediatric T1D research. The contribution from developing countries especially from Southeast Asia is meager despite a large disease burden.

Effect of Probiotic Administration on Serum Tryptophan Metabolites in Pediatric Type 1 Diabetes Patients.

Type 1 diabetes (T1D) is characterized by anomalous functioning of the immuno regulatory, tryptophan-catabolic enzyme indoleamine 2,3 dioxygenase 1 (IDO1). In T1D, the levels of kynurenine—the first byproduct of tryptophan degradation via IDO1—are significantly lower than in nondiabetic controls, such that defective immune regulation by IDO1 has been recognized as potentially contributing to autoimmunity in T1D. Because tryptophan catabolism—and the production of immune regulatory catabolites—also occurs via the gut microbiota, we measured serum levels of tryptophan, and metabolites thereof, in pediatric, diabetic patients after a 3-month oral course of Lactobacillus rhamnosus GG. Daily administration of the probiotic significantly affected circulating levels of tryptophan as well as the qualitative pattern of metabolite formation in the diabetic patients, while it decreased inflammatory cytokine production by the patients. This study suggests for the first time that a probiotic treatment may affect systemic tryptophan metabolism and restrain proinflammatory profile in pediatric T1D.

Bone turnover markers during the remission phase in children and adolescents with type 1 diabetes.

In rodents, osteocalcin (OCN) stimulates insulin production and insulin sensitivity, both important factors during partial remission in humans with type 1 diabetes (T1D). However, decreased OCN has been reported in both adult and pediatric T1D. This study aims at investigating bone turnover and partial remission in children and adolescents with recent onset T1D. Ninety-nine individuals (33% girls) were recruited within 3 months of T1D onset and examined three times, 6 months apart. Outcome variables were bone formation markers OCN and procollagen type 1 amino-terminal propeptide (P1NP) and the bone resorption marker C-terminal crosslinked telopeptide of type 1 collagen (CTX). Dependent variables included IDAA1c (surrogate marker of partial remission), total body bone mineral density (BMD) and stimulated C-peptide as representative of endogenous insulin production. OCN- and P1NP Z-scores were significantly decreased throughout the study, whereas CTX Z-scores were increased. None of the bone turnover markers changed significantly between visits. Total body BMD Z-score did not change during the study but was significantly higher than the reference population at visit 2 (P = .035). There were no differences in the bone turnover markers for those in partial remission as defined by either C-peptide or IDAA1c at any visit. The individual change in CTX Z-score was negatively associated with the increase of IDAA1c (P = .030) independent of C-peptide decline (P = .034). Bone turnover markers indicate increased bone resorption and decreased bone formation during the first year of T1D. The negative association between bone resorption and IDAA1c might represent compensatory mechanisms affecting insulin sensitivity.

Assessing awareness of hypoglycemia in children and adolescents with type 1 diabetes: Evaluation of established questionnaires.

To evaluate the use of two questionnaires assessing awareness of hypoglycemia, in a pediatric type 1 diabetes (T1D) population. Prospective observational study with children (aged 9-18 years) and parents (for children aged 2-11 years) answering the Gold and Clarke questionnaires assessing awareness of hypoglycemia. Psychometric properties of the questionnaires were evaluated, and the most appropriate cut-off score to classify participants as having normal vs impaired awareness of hypoglycemia (IAH) was determined by ability to recognize subsequent hypoglycemia and hypoglycemia severity, documented in a 4-week blood glucose diary. Questionnaires were readministered at follow-up assessment approximately 1.5 years later. In total, 112 participants (51% male) with median (IQR) age 13.7 (11.1-15.8) years, T1D duration 4.7 (2.2-7.8) years, and HbA1c 62 (57-73) mmol/mol (7.8%) were included. Both questionnaires demonstrated acceptable psychometric properties. Using score ≥3 to classify IAH gave a prevalence of IAH of 41% (Gold) and 22% (Clarke). When classified using the Gold questionnaire, IAH participants had higher incidences of mild asymptomatic hypoglycemia, whereas with the Clarke questionnaire, they had higher incidences of clinically significant and severe hypoglycemia. Subgroup analyses confirmed these associations only in participants aged ≥9 years. Follow-up was completed in 90% of the participants, and a change of awareness status was observed in 22% to 36%. The Gold and Clarke questionnaires may be used to assess awareness of hypoglycemia in pediatric T1D in those ≥9 years of age, but the more detailed Clarke questionnaire has higher specificity and is superior in predicting risk of clinically significant hypoglycemia.

Assessing Allied Health-Care Professional Time in Pediatric Type 1 Diabetes: Associations With Clinical Factors, Technology and Social Determinants

ObjectivesThe factors associated with allied health-care professional (HCP) time spent face-to-face with patients in clinic have not been well described in type 1 diabetes (T1D) given the introduction of resource-intensive technologies and gaps in socioeconomic circumstances. The objective of this study was to evaluate clinical and social factors associated with nonphysician HCP time in a pediatric T1D practice. MethodsNonphysician HCP workload data, including time spent in direct clinical care over a 1-year period and nonclinic contacts, were linked to data from 723 pediatric subjects with T1D and evaluated in relation to key demographic, social and diabetes treatment factors. ResultsHCPs spent 145.7 min per patient on a median of 3 clinic visits, with certified diabetes educators (CDEs) being responsible for most clinic interactions compared with psychosocial staff. CDE time varied considerably according to T1D duration, with new-onset patients (≤1 year) taking a median of 392.0 min compared with 114.5 min for their established counterparts (p<0.0001). Among the established group (n=629), CDE time was strongly associated with continuous subcutaneous insulin infusion therapy initiation, psychosocial service use, glycated hemoglobin (A1C) and degree of marginalization (p<0.0001). Overall, CDE time increased by 8.6 min for each 1.0% increase in A1C (p=0.022) and by 16.3 min for each 1-U increase in marginalization (p=0.01). ConclusionsWe observed HCP time was associated with multiple clinical factors in addition to overall marginalization. Although initial investments in education and continuous subcutaneous insulin infusion training were considerable, our results suggest that these lead to a decrease in time spent in clinic over time, and is largely driven by lower A1C.

Executive task-based brain function in children with type 1 diabetes: An observational study.

BackgroundOptimal glycemic control is particularly difficult to achieve in children and adolescents with type 1 diabetes (T1D), yet the influence of dysglycemia on the developing brain remains poorly understood.Methods and findingsUsing a large multi-site study framework, we investigated activation patterns using functional magnetic resonance imaging (fMRI) in 93 children with T1D (mean age 11.5 ± 1.8 years; 45.2% female) and 57 non-diabetic (control) children (mean age 11.8 ± 1.5 years; 50.9% female) as they performed an executive function paradigm, the go/no-go task. Children underwent scanning and cognitive and clinical assessment at 1 of 5 different sites. Group differences in activation occurring during the contrast of “no-go > go” were examined while controlling for age, sex, and scan site. Results indicated that, despite equivalent task performance between the 2 groups, children with T1D exhibited increased activation in executive control regions (e.g., dorsolateral prefrontal and supramarginal gyri; p = 0.010) and reduced suppression of activation in the posterior node of the default mode network (DMN; p = 0.006). Secondary analyses indicated associations between activation patterns and behavior and clinical disease course. Greater hyperactivation in executive control regions in the T1D group was correlated with improved task performance (as indexed by shorter response times to correct “go” trials; r = −0.36, 95% CI −0.53 to −0.16, p < 0.001) and with better parent-reported measures of executive functioning (r values < −0.29, 95% CIs −0.47 to −0.08, p-values < 0.007). Increased deficits in deactivation of the posterior DMN in the T1D group were correlated with an earlier age of T1D onset (r = −0.22, 95% CI −0.41 to −0.02, p = 0.033). Finally, exploratory analyses indicated that among children with T1D (but not control children), more severe impairments in deactivation of the DMN were associated with greater increases in hyperactivation of executive control regions (T1D: r = 0.284, 95% CI 0.08 to 0.46, p = 0.006; control: r = 0.108, 95% CI −0.16 to 0.36, p = 0.423). A limitation to this study involves glycemic effects on brain function; because blood glucose was not clamped prior to or during scanning, future studies are needed to assess the influence of acute versus chronic dysglycemia on our reported findings. In addition, the mechanisms underlying T1D-associated alterations in activation are unknown.ConclusionsThese data indicate that increased recruitment of executive control areas in pediatric T1D may act to offset diabetes-related impairments in the DMN, ultimately facilitating cognitive and behavioral performance levels that are equivalent to that of non-diabetic controls. Future studies that examine whether these patterns change as a function of improved glycemic control are warranted.

Adherence to multiple medications in the TODAY (Treatment Options for type 2 Diabetes in Adolescents and Youth) cohort: effect of additional medications on adherence to primary diabetes medication.

Background Non-adherence to diabetes medication leads to poor outcomes and increased healthcare costs. Multiple factors affecting adherence in adults with type 2 diabetes (T2D) have been identified, but pediatric data is sparse. We aimed to determine whether initiation of additional oral medications or insulin affects adherence to primary study medication (PSM) in the Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY) study. Methods Six hundred and ninety-nine youth (aged 10-17 years) with recent-onset T2D were randomized in the TODAY study. Participants were categorized as adherent (≥80% taken by pill count) or non-adherent (<80%), and adherence was compared between those on additional medications or not. Subgroup analyses to assess influence of race/ethnicity, gender, medication type, or depression were performed. Results At 36 months, 46.3% of participants were taking additional oral medications and 31.9% were on insulin. There was no difference in study medication adherence with additional oral medications (55.1%, 67.1%, and 56.7% at month 36 in those prescribed 0, 1, or 2+ additional medications; p = 0.16). Girls on oral contraceptives (OC) had higher adherence (65.2% vs. 55.8% at month 36; p = 0.0054). Participants on insulin had lower adherence (39.7% vs. 59.3% at 36 months; p < 0.0001). There was decreased adherence in participants with baseline depression (p = 0.008). Conclusions Additional oral medications did not influence adherence to diabetes medications in TODAY. Addition of insulin led to reduced adherence. In subgroup analyses, OC use was associated with higher adherence in girls, while baseline depression was associated with lower adherence overall. Further studies examining potentially modifiable risk factors of adherence in pediatric T2D are needed.

Impaired Phagocytosis in Dendritic Cells From Pediatric Patients With Type 1 Diabetes Does Not Hamper Their Tolerogenic Potential.

Type 1 diabetes (T1D) is prompted by defective immunological tolerance, an event in which dendritic cells (DCs) are crucial as immune response orchestrators. In fact, they contribute to maintaining tolerance to self-antigens, but they can also prompt an immunogenic response against them, leading to autoimmunity. Countless factors can potentially impact on the proper functionality of the DCs, which range from altered subset distribution, impaired phagocytic function to abnormal gene expression. Moreover, in T1D, metabolic dysregulation could impair DC functions as well. Indeed, since T1D clinical course is likely to be more aggressive in children and adolescents and entails severe dysglycemia, the aim of this study was to analyze circulating DCs subpopulations in pediatric T1D at different stages, as well as to characterize their phagocytosis ability and tolerance induction potential. Thus, pediatric patients newly diagnosed with T1D, with established disease and control subjects were recruited. Firstly, DCs subsets from peripheral blood were found quantitatively altered during the first year of disease, but recovered in the second year of progression. Secondly, to study the tolerogenic functionality of DCs, liposomes with phosphatidylserine (PS) were designed to mimic apoptotic beta cells, which are able to induce tolerance, as previously demonstrated by our group in DCs from adult patients with T1D. In this study, monocyte-derived DCs from pediatric patients with T1D and control subjects were assessed in terms of PS-liposomes capture kinetics, and transcriptional and phenotypic changes. DCs from pediatric patients with T1D were found to phagocyte PS-liposomes more slowly and less efficiently than DCs from control subjects, inversely correlating with disease evolution. Nonetheless, the transcription of PS receptors and immunoregulatory genes, cytokine profile, and membrane expression of immunological markers in DCs was consistent with tolerogenic potential after PS-liposomes phagocytosis. In conclusion, T1D progression in childhood entails altered peripheral blood DCs subsets, as well as impaired DCs phagocytosis, although tolerance induction could still function optimally. Therefore, this study provides useful data for patient follow-up and stratification in immunotherapy clinical trials.

Families with pediatric type 1 diabetes: A comparison with the general population on child well-being, parental distress, and parenting behavior.

The aim of this study was to compare families with a child (2-12 years) with type 1 diabetes (T1D) to families which are not confronted with chronic illness, with regard to children's well-being, parental distress, and parenting behavior. In addition, differences were explored between families whose child has optimal vs suboptimal glycemic control. Mothers, fathers, and children of 105 families with pediatric T1D completed questionnaires assessing child well-being, parental distress, and parenting. The control group consisted of 414 families without chronic illness. With regard to child well-being, children with T1D had more adjustment difficulties (as reported by mothers) and lower quality of life (QoL) (as reported by mothers and fathers), whereas children themselves (8-12 years) reported higher QoL compared to controls. In terms of parental distress, mothers, but not fathers, of children with T1D reported more stress, anxiety symptoms, and depressive symptoms than controls. With regard to parenting behavior, parent reports revealed less protectiveness in fathers and less autonomy support and responsiveness in both parents as compared to controls. No differences were found in parent-reported psychological control between parents of children with and without T1D, but children with T1D perceived lowered parental psychological control. Lastly, secondary analyses indicated that especially families with suboptimal child glycemic control showed more maternal distress and worse child well-being (according to parents). Families confronted with pediatric T1D differ from families without chronic illness: childhood T1D impacts parental perceptions of child well-being and differentially affects mothers' and fathers' distress levels and behaviors.

Identifying sources of support and barriers to physical activity in pediatric type 1 diabetes

Reports suggest that children with type 1 diabetes (T1D) perform less than the recommended daily activity and are less active than their non-diabetic peers. We aimed to: (a) Identify barriers and sources of support for exercise performance in pediatric T1D. (b) Identify strengths and limitations in the exercise-directed education provided by our diabetes team. Patients with T1D 5 to 20 years of age were recruited while attending a routine clinic visit. Participants completed a set of questionnaires assessing demographics, health data, barriers, and sources of support for exercise performance and diabetes related exercise education. The clinics' medical staff filled-out a questionnaire assessing the exercise-directed education provided in clinic. Ninety-six subjects were included in this study, mean age 13.7 ± 3.8 years. Median weekly reported exercise time was 3.5 hours. The two most prevalent barriers were fear of hypoglycemia and low fitness, reported by 76% and 51%, respectively. Mean family and social support scores were 4.1 ± 0.7 and 3.3 ± 1.1, respectively (1-5 scale); the latter correlated with the amount of activity performed (cc = 0.360; P < .001). The majority of participants (97%) reported receiving guidance for physical activity, to their satisfaction. Yet, knowledge and implementation were suboptimal. All staff members reported conducting routine exercise-directed teaching, with variations in frequency and content. Our findings suggest that in order to increase the amount of safely performed exercise in pediatric patients with T1D, fear of hypoglycemia must be addressed. Further efforts should focus on: (a) encouraging active family and social involvement (b) standardization of education.

Central Corneal Thickness can be Related to Diabetic Peripheral Neuropathy in Children with Type 1 Diabetes.

Diabetic eye disease with its various manifestations as well as diabetic neuropathy may occur in patients with type 1 diabetes (T1D) after several years of diabetes duration. Pachymetry is a promising method evaluating central corneal thickness (CCT) in diabetic patients. The aim of the study was to evaluate the CCT values in children with T1D and its relationship to neurophysiological markers of diabetic neuropathy. The study groups included 119 T1D children with average 5.3 years of diabetes duration and 38 age-matched controls. CCT index was measured with pachymeter in all subjects and in 19/119 of T1D patients the CCT values were referred to the ENG-EMG-SSR study results. In T1D patients the higher CCT values were observed as compared to healthy controls (p=0.037). Correlations between CCT values and both distal latency of the motor fibers of the median nerve (R=0.51; p=0.044) and conduction velocity of this nerve (R=-0.55; p=0.027) were noted. A conduction velocity of the sensory fibers of sural nerve correlated negatively with CCT index (R=-0.50; p=0.045) in the T1D patients. CCT measurement may be helpful in the referral of the asymptomatic pediatric T1D patients to assess an early stage of diabetic neuropathy.

1384-P: The Guided Transition of Care

Objective: Every year 500,000 youths in the U.S. with chronic disease need transfer to adult providers. Diabetes is a model of chronic illness that transcends age. For those with type 1 diabetes (T1D), 58% report a bad transition experience, the majority change adult providers and there is a 21% drop in clinic visits. Retrospective studies show unstructured transfers result in worse A1c. Despite the need, there is a lack of evidence-based interventions on the organization of care. Meta-analysis established engagement and retention in adult care as appropriate outcomes. Sustained continuity of care improves patient satisfaction and reduces hospital visits. We hypothesized that a physician trained in both adult and pediatric endocrinology would have greater show rates for patients transferred to adult care if he or she first provides care to the patient in the pediatric clinic. In this “guided transition” the doctor continues caring for the patient from pediatric to adult clinic. Methods: We conducted a prospective cohort study of patients with T1D, age 16-26 years, referred to adult T1D clinic and seen by a physician trained in adult and pediatric endocrinology. Patients were grouped based on if their referral originated from another pediatric endocrinologist or if the dual-trained physician previously saw the patient in the pediatric T1D clinic. Transfer to adult care occurred when physician and patient felt it appropriate. The primary outcome was show rate at the first and second adult visits. Results: Of 22 patients, 9 were referred from a different pediatric endocrinologist and 13 underwent guided transition. Both groups had similar initial A1c (p = 0.54). For patients seeing a different pediatric provider, the show rate to the first and second visit was 44% compared to 100% in the guided transition group (p = 0.003). The guided transition group maintained A1c (p = 0.79). Conclusions: The guided transition group was significantly more likely to attend adult clinic than those seeing the provider for the first time. These findings deserve broader replication. Disclosure R. Lal: Consultant; Self; Abbott. D.M. Maahs: Advisory Panel; Self; Novo Nordisk Inc. Consultant; Self; Abbott, Sanofi. Research Support; Self; Dexcom, Inc., Tandem Diabetes Care. C. Dosiou: None. T. Aye: None. M. Basina: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases (T32DK007217)

1367-P: Effect of Nationwide Reimbursement of Sensor-Augmented Pump (SAP) Therapy in a Paediatric Type 1 Diabetes (T1D) Population on HbA1c, Hypoglycaemia, and Quality of Life (QoL) According to Age Groups in the RESCUE-Paediatrics Study

Background: Long-term real-life data of SAP in pediatric T1D patients are scarce. Objectives: To assess the impact of 12 months use of SAP in a nationwide study of pediatric T1D patients on HbA1c, hypoglycemia and quality of life1 according to age. Methods: Between 12/2014 and 02/2017, 75 children entered Belgian reimbursement system for SAP and were followed for 12 months. Study endpoints included change in HbA1c at 0-4-8-12 months; time-in-hypoglycemia (&amp;lt;70mg/dl) and time-in-severe-hypoglycemia (&amp;lt;50mg/dl) (%/day) at 0-12 months; and QoL2 at 0-12 months. Puberty was defined as age ≥11.6y in boys and ≥11.2y in girls. Results: Seventy-three patients used SAP for 12 months. Baseline HbA1c (7.2±0.7%) decreased to 7.1±0.8% at 4 months (p=0.02), remained stable at 8 months (p=0.03) and 12 months (p=0.15). In pubertal children (n=29) baseline was 7.1±0.7%. It decreased to 6.8±0.7% at 4 months (p=0.003), increased to 7.0±0.8% at 8 months (p=0.02) and to 7.1±0.8% at 12 months (p=0.20). In prepubertal children (n=43) baseline Hb1Ac was 7.3±0.7%; and evolved towards 7.1±0.8% at 12 months (p=0.40). In pubertal children, time-in-hypoglycemia decreased from 7.1±6.9% to 5.7±5.1% (p=0.06) the first year, while time-in-severe-hypoglycemia did not significantly change (1.0±1.7% to 1.3±2.0%). In prepubertal children, both parameters did not significantly change (5,9±5,4% to 5,6±3,4% - 0,8±1,4% to 1,1±1,4%). In pubertal children and their parents, QoL did not significantly change. In prepubertal children, satisfaction scores improved after 12months from 67±12 to 70±9 (p=0.026). Conclusions: One year reimbursement of SAP in pediatric T1D patients improved HbA1c in the first 8 months in all; tended to decrease hypoglycemia in pubertal children; while improving QoL in prepubertal children. 1RESCUE-NCT02601729. 2Impact, satisfaction, worry (children) and parents. Disclosure F. De Ridder: None. S. Jacobs: None. S. Charleer: Other Relationship; Self; Roche Diabetes Care. P. Gillard: None. K. Casteels: None. S. Van Aken: None. I. Gies: None. G. Massa: None. P.A. Lysy: None. K. Logghe: None. M. Lebrethon: None. S. Depoorter: None. K.J. Ledeganck: None. C. De Block: None. M. den Brinker: None.

1265-P: The Paradox of Care Delivery for Type 1 Diabetes in Primary Care Settings: A Call for Interventions to Reduce Health Disparities

Adults and children with type 1 diabetes (T1D) in the U.S. do not meet targets for HbA1c. These deficits are even more pronounced based on race/ethnicity and socioeconomic status (SES). Most studies on T1D health outcomes focus on data from endocrinology clinics, yet, primary care clinics play a central role in the management of patients, especially those affected by health disparities. To better understand barriers for individuals with T1D in primary care settings, survey research was conducted with 110 Primary Care Providers (PCPs) in Florida (n=52) and California (n=58) using publicly available state-wide provider directories. Surveys were completed by PCPs in a range of settings including solo (20%), multi-specialty group (35%), single-specialty group (21%), hospital/hospital-owned systems (12%) and ‘other’ (12%). For pediatric T1D populations, 58% of PCPs reported referring children to endocrinologists for diabetes care and only 45% checked HbA1c for children with T1D during clinic visits. For adult T1D populations, 30% of PCPs referred patients to endocrinologists and 65% checked for HbA1c. Overall, providers expressed a lack of confidence in caring for T1D patients, especially when it came to technologies like CGMs (only 28% said they were “moderately” or “extremely” confident herein) and insulin pumps (only 17% said they were “moderately” or “extremely” confident). The lack of confidence surrounding diabetes-technologies was especially evident for PCPs in practice 1-10 years or 31+ years (p&amp;lt;.05 for CGMs and p&amp;lt;.01 for pumps). Despite the lack of confidence in caring for patients with T1D, 73% of PCPs reported filling an insulin prescription for a T1D patient in the last year. Surveys with PCPs from a range of clinical settings demonstrate gaps in delivering standard of care and concurrently reveal the critical role PCPs play in T1D care. Efforts to improve outcomes in T1D must include targeted interventions in primary care settings. Disclosure A.F. Walker: None. N. Cuttriss: None. M.J. Haller: Advisory Panel; Self; Pancreum, SAB Biotherapeutics. K. Yabut: None. C. Anez-Zabala: None. R. Lal: Consultant; Self; Abbott. E. Sheehan: None. M. Basina: None. K.K. Hood: Consultant; Self; Lilly Diabetes. Research Support; Self; Dexcom, Inc. Speaker's Bureau; Self; Johnson &amp; Johnson Diabetes Institute. A. Bernier: None. L.G. Baer: None. S.L. Filipp: None. C. Wang: None. M. Town: None. M.J. Gurka: None. D.M. Maahs: Advisory Panel; Self; Novo Nordisk Inc. Consultant; Self; Abbott, Sanofi. Research Support; Self; Dexcom, Inc., Tandem Diabetes Care. Funding The Leona M. and Harry B. Helmsley Charitable Trust