Person:

Wolpert, Howard A.

Objective: This qualitative study aimed to explore the experience of transition from pediatric to adult diabetes care reported by posttransition emerging adults with type 1 diabetes (T1D), with a focus on preparation for the actual transfer in care. Methods: Twenty-six T1D emerging adults (mean age 26.2±2.5 years) receiving adult diabetes care at a single center participated in five focus groups stratified by two levels of current glycemic control. A multidisciplinary team coded transcripts and conducted thematic analysis. Results: Four key themes on the process of transfer to adult care emerged from a thematic analysis: 1) nonpurposeful transition (patients reported a lack of transition preparation by pediatric providers for the transfer to adult diabetes care); 2) vulnerability in the college years (patients conveyed periods of loss to follow-up during college and described health risks and diabetes management challenges specific to the college years that were inadequately addressed by pediatric or adult providers); 3) unexpected differences between pediatric and adult health care systems (patients were surprised by the different feel of adult diabetes care, especially with regards to an increased focus on diabetes complications); and 4) patients’ wish list for improving the transition process (patients recommended enhanced pediatric transition counseling, implementation of adult clinic orientation programs, and peer support for transitioning patients). Conclusion: Our findings identify modifiable deficiencies in the T1D transition process and underscore the importance of a planned transition with enhanced preparation by pediatric clinics as well as developmentally tailored patient orientation in the adult clinic setting.

Abstract Background: Traditionally, insulin bolus calculations for managing postprandial glucose levels in individuals with type 1 diabetes rely solely on the carbohydrate content of a meal. However, recent studies have reported that other macronutrients in a meal can alter the insulin required for good postprandial control. Specifically, studies have shown that high-fat (HF) meals require more insulin than low-fat (LF) meals with identical carbohydrate content. Our objective was to assess the mechanisms underlying the higher insulin requirement observed in one of these studies. Materials and Methods: We used a combination of previously validated metabolic models to fit data from a study comparing HF and LF dinners with identical carbohydrate content in seven subjects with type 1 diabetes. For each subject and dinner type, we estimated the model parameters representing the time of peak meal-glucose appearance (τm), insulin sensitivity (SI), the net hepatic glucose balance, and the glucose effect at zero insulin in four time windows (dinner, early night, late night, and breakfast) and assessed the differences in model parameters via paired Wilcoxon signed-rank tests. Results: During the HF meal, the τm was significantly delayed (mean and standard error [SE]: 102 [14] min vs. 71 [4] min; P = 0.02), and SI was significantly lower (7.25 × 10−4 [1.29 × 10−4] mL/μU/min vs. 8.72 × 10−4 [1.08 × 10−4] mL/μU/min; P = 0.02). Conclusions: In addition to considering the putative delay in gastric emptying associated with HF meals, we suggest that clinicians reviewing patient records consider that the fat content of these meals may alter SI.

Importance: Optimization of glycemic control is critical to reduce diabetes related complications, but long-term success is challenging. Although vision loss is among the greatest fears of individuals with diabetes, comprehensive personalized diabetes education and risk assessments are not consistently employed in ophthalmology settings. Objective: To determine whether point-of-care measurement of HbA1c and personalized diabetes complication risk assessments performed during retinal ophthalmology visits improve glycemic control as assessed by HA1c. Design/Setting: Ophthalmologist office based clinical trial where investigators from 42 sites were randomly assigned to provide either study-prescribed augmented diabetes assessment and education, or usual care. Participants: Adults with type 1 or 2 diabetes enrolled into two cohorts: “more frequent” than annual follow-up (502 control and 488 intervention participants) and “annual” follow-up (368 and 388 participants). Intervention(s): Point-of-care measurement of HbA1c, blood pressure, and retinopathy severity; individualized estimate of retinopathy progression risk derived from the visit findings; structured comparison and review of past and current clinical findings; and structured education with immediate assessment and feedback regarding participant understanding. Intervention was performed at enrollment and routine ophthalmic follow-up visits scheduled at least 12 weeks apart. Main Outcome Measure(s): Mean change in HbA1c from baseline to 1 year. Secondary outcomes included body mass index, blood pressure, and diabetes self-management practices and attitudes surveys. Results: In the “more frequent” cohort, mean (SD) change in HbA1c at 1 year was −0.1% (1.5%) in the control group and −0.3% (1.4%) in the intervention group (adjusted mean difference −0.09%, 95% confidence interval −0.29% to +0.12%, P=0.35). In the “annual” cohort, mean (SD) change in HBA1c was 0.0% (1.1%) and −0.1% (1.6%), respectively (mean difference −0.05%, 95% confidence interval −0.27% to +0.18% P=0.63). Results were similar for all secondary outcomes. Conclusions and Relevance: Long-term optimization of glycemic control is not achieved by a majority of individuals with diabetes. Addition of personalized education and risk assessment during retinal ophthalmology visits, as provided in this study, did not result in HbA1c improvement compared with usual care over 1 year. These data suggest that optimizing glycemic control remains a substantive challenge requiring interventional paradigms other than those examined in this study.