Objective. Screening for type 1 diabetes provides an opportunity to identify those with pre-symptomatic, early-stage disease, enabling increased monitoring to prevent diabetic ketoacidosis and facilitating access to emerging therapies. Given potential benefits, discussions about population-wide type 1 diabetes screening are ongoing. Routine primary care visits could offer a scalable approach to such screening. We used mixed methods to explore multilevel barriers to and facilitators of type 1 diabetes autoantibody screening at well-child visits and, more broadly, the acceptability, appropriateness, and feasibility of such a screening approach. Research Design and Methods. Semi-structured interviews were completed with parents, clinicians, and health insurers. Transcripts were double coded using an iteratively adapted a priori codebook. A survey leveraging the validated Acceptability of Implementation, Intervention Appropriateness, and Feasibility of Intervention Measures instruments was deployed to assess pediatric primary care clinician perspectives. Results. A total of 26 parents, 10 clinicians (endocrinologists and pediatricians), and two health insurers participated in interviews, and 15 pediatricians participated in the survey. Most parents interviewed and clinicians surveyed found type 1 diabetes screening acceptable and appropriate. Parents noted lack of education, need for a blood draw, costs, difficulty scheduling, and fear of results as barriers. Clinicians reflected barriers including parental views on blood draws and clinician time. Insurers described lack of insurance coverage as a barrier. Facilitators across constituents included education, reduced costs, convenient screening, guidelines supporting screening, and institutional support. Conclusion. If population screening for type 1 diabetes is pursued, models that integrate primary care will be needed. Screening for type 1 diabetes through primary care well-child visits could enable high adoption if implementation strategies adequately address described barriers and promote facilitators. Key Points · Early childhood screening for type 1 diabetes provides an opportunity to identify individuals with presymptomatic, early-stage disease and intervene to prevent diabetic ketoacidosis. · Mixed methods were used to explore multilevel barriers and facilitators to type 1 diabetes autoantibody screening in pediatric well-child visits, and, more broadly, the implementation outcomes of acceptability, appropriateness, and feasibility. · Most parents and clinicians who participated in this study found type 1 diabetes screening during pediatric well-child visits to be acceptable and appropriate. Implementation barriers (e.g., costs) and facilitators (e.g., education) were identified. · Screening for type 1 diabetes within pediatric well-child visits could be a viable strategy if implementation strategies address identified barriers and promote facilitators.
In the United States, >2 million people are projected to be diagnosed with cancer in 2025, and ~20% of these patients will have a diabetes diagnosis (1–3). Hyperglycemia and cancer have a bidirectional relationship, and managing blood glucose in patients with cancer is complex because hyperglycemia may result from the underlying cancer or from anticancer or supportive care therapies that are administered intermittently (2). Hyperglycemia can worsen survival and increase risks of cancer recurrence, infection, hospitalization, toxicity, and morbidity (2). Allogeneic hematopoietic cell transplant (HCT) recipients are especially vulnerable because of insulin resistance and the use of immunosuppressants such as calcineurin inhibitors and corticosteroids for the prophylaxis and treatment of graft-versus-host disease (GVHD) (4,5). Additionally, 20–60% of patients with cancer experience treatment-induced hyperglycemia from agents such as immune checkpoint inhibitors, mammalian target of rapamycin inhibitors, phosphoinositide 3‐kinase inhibitors, and epidermal growth factor inhibitors (2).
Type 1 diabetes is a risk factor for developing mental health disorders, particularly disordered eating. Female adolescents are vulnerable to abnormal eating behaviors when transitioning from childhood to adult diabetes management. The challenge of achieving glycemic stability while navigating developmental changes during adolescence can lead females to unhealthy eating patterns as a coping mechanism. Disordered eating behavior is a term that encompasses a variety of patterns that do not meet the criteria for a formal eating disorder diagnosis. Such behaviors include dietary restriction, binge eating, and purging methods, including self-induced vomiting, excessive exercise, and medication misuse. The intentional omission of insulin is a purging method specific to diabetes, and especially type 1 diabetes. Without insulin, the body is unable to take up glucose from the bloodstream, resulting in hyperglycemia. A prolonged state of hyperglycemia can lead to serious complications, including diabetic ketoacidosis. A persistently elevated A1C is one of the few objective findings of disordered eating in patients with type 1 diabetes. Disordered eating instruments, including the SCOFF and Diabetes Eating Problem Survey–Revised questionnaires, have been adjusted to inquire about insulin misuse. Positive screening results and clinical findings of sustained hyperglycemia are pathognomonic of disordered eating behavior. Treatment of the concurrent conditions includes cognitive behavioral therapy with a multidisciplinary approach to regain glycemic stability. Health care providers must maintain a high index of suspicion for signs of psychosocial distress in female adolescents with type 1 diabetes to ensure that appropriate interventions are made before long-term complications arise.
Endogenous hypercortisolism (Cushing syndrome) is a multisystemic disease characterized by a wide range of clinical signs and symptoms. Its heterogeneous presentation can cause significant diagnostic delays, and prolonged exposure to excess cortisol activity can contribute to cardiometabolic abnormalities such as diabetes. When diabetes remains unresponsive or only partially responsive to standard-of-care treatment, clinicians should consider hypercortisolism as a potential underlying driver. Despite the risks associated with hypercortisolism, guidance on identifying and managing it in patients with diabetes remains limited. This article presents a case series of 10 patients from a single practice who were screened for hypercortisolism because of difficult-to-manage diabetes and additional comorbidities. All patients were treated for hypercortisolism with mifepristone, resulting in significant clinical improvements including weight loss, improved glycemic control, and reduced medication needs. This real-world case series highlights the importance of recognizing hypercortisolism as a differential diagnosis and a potential contributing factor to difficult-to-manage diabetes despite standard-of-care therapies. Addressing hypercortisolism with mifepristone can result in substantial clinical benefits.
Globally, >10% of adults aged 20–79 years (537 million people) are living with diabetes, and the burden is predicted to rise to 643 million (11.3%) by 2030 and to 783 million (12.2%) by 2045. An additional 240 million are estimated to live with undiagnosed diabetes (1). Diabetes was the sixth leading driver of disability in the world in 2015 (2). It is further estimated that ~90% of people with undiagnosed diabetes live in low-income countries (LICs), especially in Africa, Southeast Asia, and the Western Pacific (1). In LICs, the prevalence of diabetes is projected to increase from 5.5% in 2021 to 6.1% in 2045 (3), which will further widen the health equity gap. For example, across sub-Saharan Africa, type 2 diabetes accounts for 90% of diabetes cases (4), and the cases of diabetes in Africa are projected to increase from 23.6 million in 2021 to 54.9 million (132%) by 2045 (3).
