OBJECTIVE To assess the use of a portable retinal camera in diabetic retinopathy (DR) screening in multiple settings and the presence of associated risk factors among children, adolescents, and young adults with type 1 diabetes. DESIGN AND METHODS Five hundred youth with type 1 diabetes of at least 1 year’s duration were recruited from clinics, diabetes camp, and a diabetes conference and underwent retinal imaging using a nonmydriatic fundus camera. Retinal characterization was performed remotely by a licensed ophthalmologist. Risk factors for DR development were evaluated by a patient-reported questionnaire and medical chart review. RESULTS Of the 500 recruited subjects aged 9–26 years (mean 14.9, SD 3.8), 10 cases of DR were identified (nine mild and one moderate nonproliferative DR) with 100% of images of gradable quality. The prevalence of DR was 2.04% (95% CI 0.78–3.29), at an average age of 20.2 years, with the youngest affected subject being 17.1 years of age. The rate of DR was higher, at 6.5%, with diabetes duration >10 years (95% CI 0.86–12.12, P = 0.0002). In subjects with DR, the average duration of diabetes was 12.1 years (SD 4.6, range 6.2–20.0), and in a subgroup of clinic-only subjects (n = 114), elevated blood pressure in the year before screening was associated with DR (P = 0.0068). CONCLUSION This study in a large cohort of subjects with type 1 diabetes demonstrates that older adolescents and young adults (>17 years) with longer disease duration (>6 years) are at risk for DR development, and screening using a portable retinal camera is feasible in clinics and other locations. Recent elevated blood pressure was a risk factor in an analyzed subgroup.

Prediabetes in youth has become a more frequent challenge facing patients, families, and providers alike. As we learn more about the natural history of prediabetes and T2DM, investigators have found distinct differences between these conditions in youth and adults, making extrapolation of adult practice problematic. Moreover, there is a lack of evidence-based management and treatment guidelines for prediabetes in youth. Although current approaches may differ, best clinical practice indicates that providers should screen at-risk youth for prediabetes, and intervene with intensive lifestyle modification through improved nutrition and exercise. In some cases, pharmacologic intervention may also be warranted, but always in the context of lifestyle and behavioral changes.

Early detection of diabetic retinopathy (DR) is imperative; however, adherence to screening guidelines is poor. We hypothesized that youth and young adults with type 1 diabetes (T1D) who met American Diabetes Association criteria for recommended DR screening at the time of the study (10 years old or greater with diabetes duration of 5 years or more) would report multiple barriers to screening and that targeted barriers and subpopulations could be identified to improve access to care. 271 youth aged 10 to 26 years with T1D of at least 5 years duration were recruited from clinic, diabetes camp, and a diabetes conference and completed a patient-reported questionnaire. 113 (41.7%) reported at least one barrier to DR screening, with missed school and work being the most common (20.7%). Older participants (P = 0.007) and those with a longer diabetes duration (P = 0.018) were more likely to report barriers to screening. Recruitment location, sex, race and ethnicity, HbA1c, insulin regimen, and clinic visit frequency were not associated with reporting at least one barrier. Slightly less than two-thirds (62.1%) of participants who responded (n = 235 out of 271) adhered to recommended screening guidelines of the time and reported having an eye exam within the past year, 24.7% 12-23 months ago, 9.8% 2 years ago or more, and 3.4% had never had a DR exam. As older patients and those with longer duration of diabetes are more likely to have DR, targeted interventions to address barriers to care, such as, missed school and work should be implemented in these groups.

Background Fathers make unique and central contributions to the health of their children. However, research in type 1 diabetes (T1D) education largely ignores the needs of fathers, including during the development of online and mobile educational materials. Objective The purpose of this study was to solicit and incorporate input from fathers of children with T1D into the design, content, and infrastructure of a suite of online diabetes self-management education and support (DSMES) resources. Methods The study took part in three phases: (1) exploratory research, (2) website and subdomain development, and (3) evaluation. Fathers of children with T1D (n=30) completed surveys and semistructured qualitative interviews. Thematic content analysis was used to identify fathers’ content and design preferences. An online DSMES website (T1DToolkit.org) and a separate mobile subdomain targeting fathers (Mobile Diabetes Advice for Dads, or mDAD) were developed. A prototype of the site for fathers was evaluated by 33 additional father participants. End user feedback was elicited via survey. Results Participants in the exploratory phase were enthusiastic about the online diabetes resources. Preferences included high-quality design, availability via mobile phone and tablet, brief text content supplemented with multimedia and interactive features, reminders via text or email, endorsement by medical professionals, and links to scientific evidence. The mDAD subdomain received high usability and acceptability ratings, with 100% of participants very likely or likely to use the site again. Conclusions The development of eHealth educational platforms for fathers of children with T1D remains an unmet need in optimizing diabetes management. This study incorporated fathers’ feedback into the development of a suite of online diabetes education resources. The findings will serve as the basis for future research to assess the clinical efficacy of the website, its subdomain targeting fathers, and additional subdomains targeting unique populations.

Objective assessment of diabetes knowledge is essential to providing effective diabetes education. There is currently no such resource or instrument designed for pediatric clinical use and validated in the target population. We developed and validated the Knowledge Assessment in T1D (KAT-1) for this purpose. The KAT-1 has a total of 109 multiple choice items divided into 11 subscales designed to be taken individually. Following a pilot study to optimize the KAT-1, a validation study was performed with 200 participants (60% privately insured; 70% female; mean child A1c 8.2%; 10% African American, 11% Hispanic), including 50 parents of children with T1D <10 years; 50 parents of children with T1D ages 11-15 years; 50 adolescents with T1D ages 11-15 years; and fifty 16-21 year olds with T1D. All completed the KAT-1, Diabetes Knowledge Test 2 (DKT2), and a demographic survey. SPSS was used to evaluate the results. The complete KAT-1 scale demonstrated strong internal consistency (Cronbach’s α = 0.92, mean score 84.6, SD = 16.1). Nine of the 11 topical subscales demonstrated strong internal consistency and each took <5 minutes to complete: Supplies/Insurance (α = 0.82, mean time = 2.3 minutes, 9 questions), Hypoglycemia (α = 0.57, time = 3.1 minutes, 8Q), Sick Days/Ketones (α = 0.73, time = 3.2 minutes, 11Q), Basic Management (α = 0.63, time = 3.7 minutes, 13Q), Insulin (α = 0.67, time = 1.7 minutes, 12Q), Pathophysiology (α = 0.66, time = 4.1 minutes, 10Q), Technology/Devices (α = 0.86, time = 2.1 minutes, 15Q), Nutrition (α = 0.51, time = 2 minutes, 7Q), and Diabetes at School (α = 0.52, time = 4.3 minutes, 9Q). Subscale scores were positively correlated with one another. Total scores were positively correlated with the DKT2 and negatively correlated with the child’s reported A1c. All correlations were significant. The validated KAT-1 facilitates objective and expedient assessment of T1D knowledge. Its subscales will be integrated into the EHR as patient-facing surveys to quickly identify individual learning needs and allow for targeted T1D education. Disclosure A. Albanese-O'Neill: None. J.W. MacInnes: None. N.T. Thomas: None. M.J. Haller: Advisory Panel; Self; Pancreum, SAB Biotherapeutics. D. Schatz: None. J. Silverstein: None. J. Adams: None. R. Oyetoro: None. B.A. Kershaw: None. K. Anderson: None. A. Bernier: None.

Objective To assess the effectiveness of behavioral parent-only (PO) and family-based (FB) interventions on child weight, dietary intake, glycated hemoglobin, and quality of life in rural settings. Methods This study was a three-armed, randomized controlled trial. Participants were children (age 8-12 years) with overweight or obesity and their parents. A FB (n = 88), a PO (n = 78) and a health education condition (HEC) (n = 83) each included 20 group contacts over 1 year. Assessment and treatment contacts occurred at Cooperative Extension Service offices. The main outcome was change in child body mass index z-score (BMIz) from baseline to year 2. Results Parents in all conditions reported high treatment satisfaction (mean of 3.5 or higher on a 4-point scale). A linear mixed model analysis of change in child BMIz from baseline to year 1 and year 2 found that there were no significant group by time differences in child BMIz (year 2 change in BMIz for FB = -0.03 [-0.1, 0.04], PO = -0.01 [-0.08, 0.06], and HEC = -0.09 [-0.15, -0.02]). While mean attendance across conditions was satisfactory during months 1-4 (69%), it dropped during the maintenance phase (42%). High attendance for the PO intervention was related to greater changes in child BMIz (p < .02). Numerous barriers to participation were reported. Conclusion Many barriers exist that inhibit regular attendance at in-person contacts for many families. Innovative delivery strategies are needed that balance treatment intensity with feasibility and acceptability to families and providers to facilitate broad dissemination in underserved rural settings.

Most individuals with type 1 diabetes (T1D) do not achieve glycemic targets, particularly in youth. This analysis examined HbA1c trajectories of youth newly diagnosed with T1D. T1D Exchange registry participants <18 years with at least one HbA1c during the year of diagnosis and ≥3 duration-year aggregated HbA1c values over 10 years of follow-up were included. At diagnosis, the 4183 participants were 48% female, 81% Caucasian, age 6±4 years, and 77% privately insured. Suboptimal control was defined as HbA1c ≥9%. Group-based trajectory modelling was used to identify unique HbA1c trajectories over aggregated duration years. Five trajectories emerged (Figure). The majority of youth had stable trajectories within three distinct categories: those at (1) or above (3) glycemic target and those with suboptimal control (4). Two groups showed deterioration over time, one with suboptimal control from diagnosis (5) while the other had above target glycemia that worsened with time (2). Minority status was higher in groups with upward trend in HbA1c trajectory and suboptimal but stable control. Similar trends were seen for non-private insurance. Several distinct patterns of HbA1c progression exist in youth with T1D, partly dependent on HbA1c at diagnosis. Identifying characteristics of those with progressive deterioration in glycemic control and designing appropriate interventions for these groups is warranted. Disclosure J. Sherr: Advisory Panel; Self; Bigfoot Biomedical, Eli Lilly and Company, Insulet Corporation. Consultant; Self; Lexicon Pharmaceuticals, Inc., Medtronic, Sanofi. Research Support; Self; Dexcom, Inc., Insulet Corporation. N.C. Foster: None. K. Bethin: Research Support; Self; Novo Nordisk Inc., Xeris Pharmaceuticals, Inc. L.A. Fox: None. L.D. Mastrandrea: Advisory Panel; Self; Pediatric Diabetes Consortium. Research Support; Self; AstraZeneca, JDRF, Novo Nordisk Inc., Sanofi-Aventis, T1D Exchange. Other Relationship; Self; Novo Nordisk Inc. B.M. Nathan: None. M.J. Redondo: None. J. Silverstein: None. J. Simmons: None. M.A. Clements: Advisory Panel; Self; Glooko, Inc. Consultant; Self; Eli Lilly and Company. Speaker's Bureau; Self; Medtronic. W.V. Tamborlane: Consultant; Self; AstraZeneca, Boehringer Ingelheim International GmbH, Eli Lilly and Company, Medtronic MiniMed, Inc., Novo Nordisk Inc., Sanofi, Takeda Pharmaceutical Company Limited. K.M. Thrailkill: None. J.C. Wong: Advisory Panel; Self; Tidepool Project. Research Support; Self; Dexcom, Inc. J. Wood: Research Support; Self; AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc., Novo Nordisk Inc.

The natural history of Insulin dependent diabetes (IDD) includes a long preclinical phase in which autoimmune destruction of pancreatic beta cells usually occurs. Azathioprine is a purine antagonist that affects delayed immunological hypersensitivity and cellular cytotoxicity. The potential oncogenic effects of immunosuppressive agents in general, and of azathioprine in particular, is one of the major deterrents to their use in trials of newly diagnosed diabetes. Patients were admitted into the study only if they had findings consistent with an autoimmune etiology for their IDD. Complete blood counts were performed every 2 weeks for 6 months, then monthly, to monitor the effects of azathioprine therapy. Trials of immunotherapy for IDD should be pursued only in a research setting using randomized study designs with as much blinding as possible. Investigators who have been involved in such studies have been uniformly impressed that more control patients develop natural remissions than they would have suspected based upon their previous experiences.

ObjectiveTo examine the association between caregiver proxy report of executive function (EF) and dysregulated eating behavior in children with obesity.MethodsParticipants were 195 youth with obesity aged 8-17 years, and their legal guardians. Youth height, weight, demographics, depressive symptoms, eating behaviors, and EF were assessed cross-sectionally during a medical visit. Analyses of covariance, adjusted for child age, gender, race/ethnicity, standardized BMI, depressive symptoms, and family income were used to examine differences in youth EF across caregiver and youth self-report of eating behaviors.ResultsYouth EF differed significantly by caregiver report of eating behavior but not youth self-report. Post hoc analyses showed that youth with overeating or binge eating had poorer EF than youth without these eating behaviors.ConclusionsExecutive dysfunction, as reported by caregivers, in youth with obesity may be associated with dysregulated eating behaviors predictive of poor long-term psychosocial and weight outcomes. Further consideration of EF-specific targets for assessment and intervention in youth with obesity may be warranted.

Objective: Current data are limited on the course of type 1 diabetes (T1D) in children and adolescents through the first few years of diabetes. The Pediatric Diabetes Consortium T1D new onset (NeOn) Study was undertaken to prospectively assess natural history and clinical outcomes in children treated at 7 US diabetes centers from the time of diagnosis. This paper describes clinical outcomes in the T1D NeOn cohort during the first 3 years postdiagnosis. Results: A total of 1048 participants (mean age 9.2 years, 49% female, 65% non-Hispanic White) were enrolled between July 2009 and April 2011. Mean glycated hemoglobin (HbA1c) (+/- SD) was 7.2% (55 mmol/mol) at 3 months, followed by a progressive rise to 8.4% (68 mmol/mol) at 36 months postdiagnosis, with only 30% of participants achieving target HbA1c<7.5% (58 mmol/mol). The percentage of participants in partial remission estimated by insulin dose adjusted HbA1c [HbA1c % + (4xinsulin dose unit/kg/24 h)] <= 9 sharply declined from 23% at 12 months to 7% at 36 months. The percentage of participants developing diabetic ketoacidosis (DKA) was 1% in the first year after diagnosis, increasing to 6% in years 2 and 3. Conclusions: These results demonstrate the gradual decline in glycemic control due to waning residual endogenous insulin secretion with increasing duration of T1D in children and adolescents. These data indicate the need to translate recent advances in automated insulin delivery, new insulin analogs, and adjunctive pharmacologic agents into novel treatment strategies to maintain optimal glycemic control even early in the course of T1D.

Objective: Few studies explore how socioeconomic status (SES) influences the allocation of type 1 diabetes (T1D) care within households. This study used survey research to better understand the perspectives and experiences of maternal caregivers who have adolescents with T1D.Research Design and Methods: Survey research with open-ended sections was conducted with women who live with another adult partner and had full custody of an adolescent 12-19 with T1D. Demographic information included age, gender, race-ethnicity, martial status, education level, occupation, and household income. Disease duration and youth HbA1c levels were also captured.Results: Forty-six caregivers completed surveys. Care allocation, diabetes strain, and parenting strategies were compared by income categories and exhibited variation accordingly. Women from households with income <$40,000, classified as low socio-economic status or less affluent, tended to report sharing diabetes-related responsibilities equally with partners; tended to hold full-time, low-wage positions; and noted stress associated with inflexible jobs and financial concerns. Women from households with incomes $80,000 or higher, classified as high socioeconomic status or more affluent, more commonly described primary caregiving, professional status changes, and difficulty transferring control to their teens.Conclusion: These findings indicate significant, yet varying, strain for women from different SES thresholds that deserves further attention. For female caregivers of adolescents with T1D, the unequal distribution of labor associated with care-related demands may contribute to outcomes like depression, anxiety, and familial conflict. Providers should be acutely aware of the toll that care-related demands may take on women and have information readily available on support groups and mental health services.

Parental support and care-coordination are vital for youth with type 1 diabetes (T1D) in achieving positive health outcomes. Yet, studies are rarely designed to identify factors that influence parent/youth collaboration or how their perspectives about diabetes may vary.

OBJECTIVE:To describe the clinical characteristics, treatment approaches, clinical outcomes, and co-morbidities of youth with type 2 diabetes (T2D) enrolled in the Pediatric Diabetes Consortium (PDC) T2D Registry. METHODS:PDC enrolled 598 youth <21 yr of age with T2D from February 2012 to July 2015 at eight centers. Data were collected from medical records and interviews with participants and/or parents and included glycated hemoglobin (HbA1c), diabetes treatments, prevalence of diabetes comorbidities (hypertension (HTN), dyslipidemia (DL), microalbuminuria (MA), and nonalcoholic fatty liver disease (NAFLD). RESULTS:Insulin use was observed in 45% of those with T2D duration <1 yr, 44% for 1-<2 yr, 55% for 2-3 yr and 60% for ≥4 yr. Median HbA1c was 6.7% (50 mmol/mol), 8.5% (69 mmol/mol), 9.6% (81 mmol/mol), and 9.7% (82 mmol/mol) in those with disease duration <1, 1-<2, 2-3 and ≥4 yr, respectively. Only 33 and 11% of those with HTN and DL respectively, were being treated. MA and NAFLD were observed in 5-6% of the participants. Prevalence of HTN was associated with higher BMI (p < 0.001), DL with higher HbA1c (p < 0.001), and MA with longer diabetes duration (p = 0.001). CONCLUSIONS:Frequency of insulin therapy in youth with T2D was associated with increased disease duration and those with longer duration rarely achieve target HbA1c level. This highlights the aggressive course of T2D in youth and adolescents. Additionally, co-morbidities are not being adequately treated. Follow up data from the PDC will provide additional important information about the natural history of T2D and patterns of gaps in treatment.

The metabolic syndrome is just as much a pediatric disease as it is a disease of adults. This chapter first defines and recognizes the metabolic syndrome, and relates insulin resistance to the pathologies of the metabolic syndrome. Next, it explains how hyperinsulinism causes component disorders of the metabolic syndrome. The chapter provides a clarification of how relative insulinopenia causes component disorders of the metabolic syndrome. It helps the reader to inter-relate decreased insulin action and hyperglycemia, and also the development of a prooxidant state. Type 1 diabetes results from absolute insulinopenia, whereas type 2 diabetes results from insulin resistance and relative insulinopenia. The consequences of insulin resistance result from (i) the direct consequences of hyperinsulinism (as an attempted physiologic compensation for insulin resistance) or (ii) inadequate insulinization (e.g., decreased insulin action) despite hyperinsulinism.

Optimal glucose control is important for the prevention of the microvascular complications in type 1 and type 2 diabetes (T2D). Although hyperglycemia is associated with oxidative stress, studies in adults have demonstrated that increased blood glucose variability can magnify this effect and may be as important or potentially, even more important, than the degree of blood glucose control in increasing the risk of microvascular and macrovascular disease. As the TODAY study demonstrated, youth with T2D have earlier appearance and more rapid progression of complications than do adults with T2D; it is important to determine if adolescents have the same effect of glycemic variability on oxidative stress as do adults.