International Society of Pediatric and Adolescent Diabetes (ISPAD) 2019 Congress

October 30-November 2, 2019; Boston, MA; Day #1 Highlights

Executive Highlights

  • The 45th Annual ISPAD Congress is underway in downtown Boston. Day #1 was full of learning – what an awesome agenda that’s been put together by the ISPAD team, led by conference co-presidents Drs. Lori Laffel and Joseph Wolfsdorf and ISPAD President Dr. Kim Donaghue. Check out our preview for a look ahead at days #2-4!

  • An afternoon session on going “beyond routine care” was left abuzz after sessions from Dr. Jennifer Raymond on the benefits of telehealth in young adults. Dr. Raymond’s CoYoT1 telehealth-based care model delivered extremely impressive results in a pilot study, with the intervention group averaging 3.5 visits/year, compared to just 1.1/year in the control group. Psychosocial outcomes were also improved in the intervention group. During her presentation and in a nearly ten-minute Q&A period, Dr. Raymond shared some tips and advice for implementing a virtual care model. We’ve been hearing about CoYoT1 for some time, and loved getting the inside scoop and multiple perspectives about what is needed on care delivery.

  • To a packed room, our own Kelly Close shared some personal stories, looking back at her experience with diabetes starting as a teenager and ahead at the potential for CGM and AID, enabled by time-in-range, diabetes apps, virtual visits, and more. Earlier in the day, we also heard Barbara Davis Center’s Ms. Laurel Messer share her learnings around successfully implementing automated insulin delivery systems and barriers around their use, and diabetes device use, in general. Everyone will deserve AID once it can be scaled and delivered safety to tends and hundreds of thousands of people with diabetes – we look so forward to the slew of options described in the presentation (if you’d like a copy of Kelly’s presentation, please let us know – it’s full of thinking that Adam Brown shared at AADE on this topic, updated with data from both!)

  • Whether or not the benefit of SGLT inhibitor use in pediatric diabetes overcomes associated risk was discussed in a nearly full session. Given recent positive news for the class, like Farxiga’s FDA approval for hHF and ESC 2019 guidelines that support its use as first-line therapy, opinions were mixed. While Drs. Bruce Perkins and Chantal Mathieu sang the class’s praises in glycemic control, weight loss, and increased quality of life, Dr. Simeon Taylor countered with hesitancy whether these effects often seen in adult, type 2 populations will extend to youth or whether the tradeoffs are worth it.

  • Dr. Doug Melton gave what we heard to be a spellbinding lecture earlier today on the stem cell front – we’ll be back with more on that next week.   

Hello from Beantown! The 45th Annual ISPAD Congress is underway, and we’re bringing you our top 5 highlights.

Top 5 Highlights

1. Lessons from CoYoT1 Trial: Telehealth Can Greatly Boost Clinic Visit Attendance, Improve Diabetes Distress; Young Adults Must Be Cared for Differently

To a packed ballroom, Dr. Jennifer Raymond (Children’s Hospital Los Angeles) gave an inspiring presentation on lessons learned from the CoYoT1 (Colorado Young Adults with Type 1; pronounced “coyote”) care model, which demonstrated huge increases in number of clinic visits (3.5 vs. 1.1 per year; p<0.001). The CoYoT1 care model substitutes traditional in-person clinic visits with a video telemedicine visit with a provider for 20-30 minutes and a group appointment where multiple young adult peers discuss issues related to their transition from childhood to adulthood (e.g., managing diabetes at work or college, managing personal relationships, etc.). The audience seemed very excited to hear so much success surrounding peer support in particular, as that is being more widely prescribed today, as we understand it. This model was piloted in Colorado with 42 self-selected participants and 39 control participants (traditional, in-person visits) around 20 years old at baseline. Results were published in DT&T in 2018, showed incredibly strong results: for the CoYoT1 group, the number of clinic visits attended per year rose from 2.6 the year before the study to 3.5 during the study. In the control group, this number decreased from 2.3 visits the year before the study to 1.1 during the study (p<0.001). Diabetes distress scale ratings dropped from 2.1 at baseline to 1.8 at the end of the study, compared to a rise from 2.0 to 2.2 for the control group (p=0.03; Bakhach et al., 2019). Additionally, despite the increases in number of clinic visits, there were no significant total cost differences between the CoYoT1 and control groups (Wen et al., 2019). This was explained by a decreased number of non-endocrinologist and hospitalization visits in the intervention group, shifting costs from acute care to preventive care – a huge win for patients and the system. After a successful pilot in Colorado, Dr. Raymond and her team worked on translating the model to Los Angeles for a lower socioeconomic status, minority population. That trial (ClinicalTrials.gov) will be run for one year as an RCT with type 1 patients ages 16-25. It is currently recruiting, and the first visits started in July this year.

  • In addition to the telehealth component of CoYoT1, the California version involves shared-decision making, self-efficacy, goal setting, and monthly debriefing. Before each visit, patients fill out a shared-decision making worksheet, in which the patient fills out topics they “definitely want to talk about” and topics they “could wait to talk about.” Brilliant! We’d say that idea could be extended to most patients in most offices as an option! Similarly, at the end of the appointment, a goal-setting worksheet is provided, giving a summary of the visit and between-visit goals. The California version of CoYoT1 also added a slightly older type 1 peer to facilitate the group visits. Interestingly, Dr. Raymond found that young adult patients often preferred having video-summaries for the visit, rather than written-form summaries. Lastly, the provider groups also met monthly with audio recordings of visits to discuss how they could make their visits more patient-centered.

  • Comparing the CoYoT1 care model to existing models, CoYoT1 is sustainable and cost-effective, while delivering improved psychosocial outcomes without the need for any additional resources (e.g., time, staff, rooms, etc.). Additionally, while patient burnout and stress from diabetes are common, Dr. Raymond also emphasized the high number of providers who experience burnout and stress. Provider experiences could be improved by moving away from current models of care, which Dr. Raymond characterized as labor and resource intensive, expensive, and not universally applicable.

  • Dr. Raymond identified several challenges and potential solutions to more widely implemented virtual care visits. For patients, providers, and institutions, learning a care model is a huge challenge; for this, Dr. Raymond emphasized that extensive practice was key, along with availability of a dedicated team for onboarding. She noted that, in her experience, telehealth visits were much more likely to be on time compared to in-person visits (due to driving times, finding parking, getting checked in, etc.), and recommended that providers stick to exclusively telehealth or in-person visits for this reason. Implementing virtual care visits may also require shuffling staff roles, as the need for employees at the front desk may be reduced, but new staff may be needed to help set up and facilitate the virtual visits.

Selected Questions and Answers

Q: What happens in between the visits? Between the three months, it’s tempting to do more, and do the patients expect you to do more? How do you deal with this?

A: Great questions. I would say young adults are really engaged when people are there and present for them. They’re reaching out more often, they’re wanting people to be able to answer their questions, they’re wanting people to trust. And as that comes to fruition, they are more engaged.

It’s challenging to plan for increased frequency of visits when you’re thinking about a clinical model. Providers often don’t have availability for more frequent appointments, and although that is the ideal, sometimes the appointments just are not available. Sometimes, there is an option to increase intensity by adding visits with additional staff members (e.g. nurses, dietitians, social workers, psychologists), and there are some easy ways to do that with a telehealth platform …

Additionally, I find that virtually, young adults are more comfortable and more honest about their care. I think there’s something about being in their setting, their own place, and being comfortable that results in a better patient-provider connection and increased sharing.

As for the questions about frequency of in-person appointments, and critical physical exam components,  if needed, we have partnered with primary care providers or asked young adults to use local pharmacies for blood pressure checks. However, we have found once per year sufficient. I actually don’t think we need frequent in-person visits to be able to support our young adults with diabetes.

Q: When patients go for each visit, is it the same person they’re seeing?

A: I think that’s something important for young adults (and likely all patients) – the need for trust and continuity. High risk patients who miss appointments or need to be seen more frequently are often added as soon as they can be – when there’s any provider available – which often means they have a different team member each time. Sometimes, I think that can be tough on these patients who likely need even more continuity. Our goal is to see the same provider at least every three months.

Q: What kind of software do you use? Is it safe and secure? Can you maintain it?

A: There are multiple different platforms that are available for virtual care that are HIPAA-secure and would be approved by a medical legal team. Risk Management and Data Safety Management experts have been involved with our platform selection. I have used different platforms at different times, and they all seem to work similarly. Working with your institution to select or learn about various platforms is important.

Q: How much time does it take to analyze the data through the virtual visit?

A: In regard to analyzing diabetes data virtually, I will just walk through how we review data during appointment. I pull up the telehealth platform, the electronic medical record system, the shared-decision making documents (both provider and patient), and then the website we’re using to download diabetes data or maybe their Clarity report. Then, you can share your appropriate computer window, so the patient and I can be looking at one another and also looking at data on my screen. We’ll go back and forth between the decision-making pieces and set the agenda for the appointment, and then we’ll switch to the diabetes data.

As providers, we’re often used to drawing on the paper downloads during in-person visits – and you can do something similar with the computer mouse, but it is a shift for providers and patients – which is why practice is important. Of note, some clinics do have diabetes data downloaded into their electronic medical record. Unfortunately, we don’t have integration with our electronic medical record yet, which is the reason for using a separate platform.

2. Quotable Quotes from Kelly Close: Looking Back at How Far the Field Has Progressed and Looking Forward at CGMs, Beyond A1c, and Diabetes Apps

In a sweeping presentation, our own Kelly Close reflected on her diabetes journey, how much the field has changed since her diagnosis, and looked ahead at technologies driving changes in diabetes management. At times, the mood was somber, with Ms. Close sharing her regret at not having expressed her gratitude towards her parents and family for helping manage her diabetes (“I was so busy just being diabetic.” Other times, the mood was jovial, with Ms. Close’s stories causing the audience to burst into laughter. In a moment where she shared how CGM and time in range are tools similar to microscopes and telescopes, she shared a story with her daughter related to her 14-year old: “I keep saying to my 14-year old, ‘Coco, how are you taller than me now?’ She says, shrugging, ‘Cell division.’” The audience nodded multiple times as Ms. Close talked about how for providers, there may be more work at the beginning with apps related to CGM or food, but that ultimately, as apps become easier, engagement will grow, and patients will become more engrossed. The heterogeneity of patients means this won’t be everyone, but our team has been astounded by the improvement in both technology and apps, and particularly automated insulin delivery, which many in the audience clearly had extensive experience. And, there’s still a long way to go – while virtually everyone had patients using CGM, we estimate about 50%-75% of patients on CGM are using apps, despite the fact that there was so much enthusiasm on apps including those for Clarity, LibreLink, Senseonics, and Medtronic.

On Her Gratitude and How Far the Field Has Progressed

  • “I’ve had diabetes for 35 years. In 1986, I was diagnosed on the way to an English class, when I just couldn’t walk. I learned about diabetes from an amazing doctor, Dr. Ingeborg van Pelt and “through inter-library loans”. That’s what we used to do, pre-Internet. So much of the work that all of you are doing is helping the families of people with diabetes so much. I always talk about my husband, who does so much for me – generally in our field, we don’t thank partners very much and we don’t thank children or parents. My parents passed away when they were very young, and I never said thank you to them for helping me with my diabetes, just because I was so busy having diabetes. Never, before I was working in diabetes full-time, did I say thank you to the doctors, the nurses, to the coordinators and manager, to the researchers – thank you for what you do. You have chosen the hardest field, and I know in many cases, it’s chosen you!”

  • “I started my own organization, Close Concerns, back in 2002. Ever since then, I’ve been able to go to multiple scientific, regulatory, and advocacy meetings every single year. That first year, in 2003, there were eight meetings – ISPAD was one of them. There were not that many scientific meetings that we could even go to, however. Looking at where the field was then, it’s amazing where you have taken it and where you have made so many changes today.”

  • “Until really recently, my identity as somebody with diabetes was ‘this is really complicated, and there are so many pieces of it that are unfair.’ I’m someone who is lucky, because I have access to so many great providers and a great family. Even when patients have this, there are things that we present that show our vulnerabilities. But, since I’ve gone on automated insulin delivery, I don’t even have hypoglycemia anymore, not much at all, or not in the same way. I now have soft landings, or I can tell that the hypoglcyemia is coming through the app, and I manage it, and have it for so much less time. The apps work so well that [when I go low] that it prevents me from having over-corrections since I don’t need to make any corrections! And then, all of the hyperglycemia that I experience comes as something I can identify as not the best food choices. The apps are making us smarter as patients and helping us see what we want to avoid.”

On CGMs and Time-in-Range

  • “Do you know what’s special about this date? 1993? [murmers in the crowd] Yes, it was DCCT! There are some amazing stories about DCCT. ADA was in Las Vegas in [1993] and I guess that ADA has never been asked back to Vegas again … Dr. Jerry Share shared with me what happened in Las Vegas: there were standing ovations at ADA, with DCCT and it’s validation of A1c and the knowledge that tighter management and lower A1cs were so positive. If you had control that was tighter, would really reduce your long-term complications. We are in a similar movement now, with time-in-range, and getting beyond A1c. It’s not about replacing A1c, but supplementing it! Today, through so much new work leveraging CGM and Time in Range, we know so much more about how A1c is not the end-all, be-all, and about how Time in Range shows us so much more and helps contextualize A1c.”

  • “And, there’s still so much amazing research to do! What do we know about Time in Range and the long-term outcomes from various patterns?” [Knowing nods.]

  • “Adam Brown compares CGM to other amazing historical tools like the microscope and telescope. In biology, the microscope taught us so much about how cells work. (My 14-year old, Coco, by the way, whenever I ask how she can possibly be taller than me, always responds ‘cell division!’) We got new understanding the component parts of different plants and animals from microscopes. Telescopes, similarly, allowed us to look at the planets and stars and understand our place in the universe. Similarly, in diabetes, CGM IS that tool for understanding what’s working and what’s not working, how food drives it glucose and out of range. These two incredible tools have amazing value. In a similar way, I think that’s where CGM is. This is an amazing tool that has helped us think about time-in-range and how we can get [better].”

  • “Not everyone gets pumps. Not everyone gets CGMs, and a lot of what I’m talking about today relates with [that tech]. Obviously, we need to get to a point where everyone who wants one, gets one. Not everyone wants one. But if they do, we need to make that possible, and then, we need to make these things as easy as possible to use. Things like replacing CGM receivers with cell phones are gamechangers, especially for teenagers.”

  • “With the discretion of seeing [your CGM data] on your phone, you can get a big increase on the number of people using these technologies.”

On Diabetes Apps and More

  • “Apps are not only very heterogenous, and they’ve really improved. When you think of how you used apps, back in the day, you might have been frustrated or your patients might have been frustrated. Now, they are improving all the time.”

  • “Seventy-eight percent of people in [dQ&A’s] panel who are using CGM use an app. That is up from closer to 50% a couple of years ago.”

  • “Not everybody has CGM, but everyone can have a connected meter. Only about 10% of people who use BGMs in [dQ&A’s] panel are actually using the connected part of those meters. We really encourage use of Glooko or Tidepool [to record data] as well as using the apps to analyze it daily or hourly.”

  • “Do you guys know ‘FNIR’? Flat, narrow, in-range. It’s so aspirational. I’m pretty much never flat or narrow, but I’m getting better at in-range. That term comes from the International Diabetes Center in Minneapolis and Dr. Rich Bergenstal and his group.”

  • “The magic of automated insulin deliveries is the soft-landings that come. You don’t have much hypoglycemia at all. So, you don’t have over-corrections ….”

  • “What happens when many more people are at 70% time-in-range? What’s the difference between people who are at 179 mg/dl and are FNIR vs. people who are at 80 mg/dl and are FNIR? What’s the difference when there’s a lot of variability? There are going to be so many interesting things as we try to tackle this massive public health problem and work to reduce long term complications leveraging technology.”

3. Laurel Messer: Even As Technology Improves, Basic Diabetes Management Education and Training Must be Maintained

The highly-regarded Ms. Laurel Messer (Barbara Davis Center) shared some practical tips for successfully implementing automated insulin delivery systems, emphasizing the need for training around delivering boluses and treating hypoglycemia, even as technology handles more of those tasks automatically. In fact, Ms. Messer called bolusing the “most important part of any technology in the next five years.” When new automated insulin delivery (AID) systems come to market, the tendency is to say to patients, “You don’t have to perform X activity anymore.” According to Ms. Messer, this is probably an overpromise; while diabetes technology certainly does have the ability to greatly reduce certain behaviors (e.g., no-calibration, non-adjunctive CGMs have significantly reduced the need for fingersticks), underplaying behavior X too early can easily result in poorer glycemic control. In the cases of bolus delivery and treating hypoglycemia, “we are not in any space to let up” on education. In line with her point on managing expectations for new AID systems, Ms. Messer recommended that these systems be turned off and to use temporary basal rates when users were sick, on steroids, etc. Lastly, she emphasized the fact that all commercial systems will only be designed to work when people aren’t trying to “fight against the system”; in other words, patients who want more control over the system’s behavior and parameters may prefer different options. As we heard from Dr. Rich Bergenstal back at ENDO 2017, the best way to use MiniMed 670G is to “let it work, let it work, let it work.”

  • To make her point, Ms. Messer shared a humorous, but telling, story about MiniMed 670G. One school nurse called her and told her that there was an emergency because one child’s 670G had gone out of Auto Mode – the nurse thought that exiting Auto Mode meant the device had completely stopped insulin delivery. To combat this type of misperception, Ms. Messer recommended that people view AID systems as the next iteration of pumps, “Pump 2.0.”

  • Ms. Messer showed results gathered from Stanford and the University of Colorado, identifying the top barriers to diabetes tech use in adolescents: hassle of wearing devices all of the time (38%), dislike having devices on the body (33%), dislike how devices look on the body (29%), nervousness that the device won’t work (25%), and not wanting to spend more time managing diabetes (20%). Similarly, a recent article in DT&T showed identified similar barriers to CGM use, though that study seemed to underscore the heterogeneity of responses to diabetes devices.

    • We heard some helpful tips for helping address barriers to device adoption utilized at Barbara Davis Center.

      • Hassle. Alerts should be minimized by always assessing glycemia goals (e.g., avoid hypoglycemia, but not hyperglycemia) and personal tolerance for alerts. Alerts should also be customized by time of day and users should consider taking occasional breaks from device use.

      • On-body discomfort. Providers should help patients choose the proper devices based on size, location of wear, waterproofing, etc. Additionally, patients should be encouraged to wear the device in a place that is convenient (“a CGM on the forearm is better than not having data”).

      • Nervousness. AID systems can be demystified by emphasizing that they are just pumps + sensors. Education around basic diabetes management, such as hypoglycemia and ketone protocols (e.g., STICH) cannot be lost.

  • As the AID landscape becomes populated with more commercial systems, Ms. Messer shared her CARES (Calculates, Adjusts, Reverts, Education, Sensor/Share) paradigm for thinking about AID systems. The framework, used to evaluate MiniMed 670G and Control-IQ in the table below, can be used by both patients and providers who do not have time to learn the ins and outs of every available AID system.

4. SGLT-2 Inhibitors for Youth and Adolescents? KOLs Debate the Drug Class’s Benefits and Risks

In a near-packed symposium in the conference’s largest room, Drs. Bruce Perkins, Chantal Mathieu, and Simeon Taylor discussed SGLT inhibitors’ potential use in pediatrics diabetes management. The drug class has been picking up steam for its cardiometabolic promise in adult populations. Examples include Farxiga’s (dapagliflozin) first-in-class indication for hospitalization for heart failure (driven by stunning DAPA-HF results), the FDA’s fast track designation to Lilly/BI’s Jardiance (empagliflozin) for chronic heart failure, and even ESC’s 2019 guidelines that promote SGLT-2 inhibitors as first-line therapy for patients at high risk for/with established CVD. Knowledge of the drug class is nowhere near sparse, with many more large scale CVOTs expected to be complete by 2021.

  • Dr. Bruce Perkins began the session with an overview of the drug class’s mechanism and potential in both type 1 and type 2 populations. He sang the class’s praises in both glycemic and cardiometabolic control. While data from the remogliflozin single-dose study and ATIRMA (on empagliflozin) validate SGLT-2s’ ability to lower A1c, data from CREDENCE supports the drug’s ability to lower risk of adverse renal outcomes. SGLT inhibitors’ ability to confer cardiorenal protection is further supported by DAPA-HF and ATTEMPT. While Dr. Perkins focused on mechanisms for glycemic, natriuretic, and cardio-renal protection, we found his discussion of DKA to be particularly enlightening. SGLT-2s have, of course, been linked to DKA, primarily because of metabolic shifts and decreased insulin doses leading to lipolysis and ketogenesis. Many opponents of extending SGLTs to youth and adolescents also argue that young patients can better manage their diabetes through automated insulin delivery, hybrid closed loop, and CGM to get the same effects as very low dose SGLT treatment. Dr. Perkins emphasizes that DKA can be overcome clinically, and patients should be able to choose from a panel of therapy and technology options to help manage diabetes.    

  • Dr. Chantal Mathieu continued with the effects of SGLT treatment in people with type 1. Current unmet needs in type 1 populations include glycemic control, high risk of hypoglycemia, weight gain, glucose variability, daily diabetes management burden, suboptimal CV risk factor control, and high CVD morbidity and mortality. The DEPICT, inTandem, and EASE studies all show drops in A1c, increased TIR, and decreases in weight and hypoglycemia, but also show side effects like DKA and genital infections. Dr. Mathieu stated that SGLT inhibitors are promising adjunct therapies for type 1 given their ability to reduce hypoglycemia, weight, and glucose variability while improving quality of life – but the right dose must be found to balance the benefits against the risks. Currently, only sotagliflozin and dapagliflozin are approved by the EMA at low doses (5 mg) to treat adult patients with BMI over 27 kg/m2. Dr. Mathieu closed her talk with her own opinions on prescribing SGLT inhibitors, stating that she’d need to know her patient’s entire medical history and only prescribe the drug to patients with A1c below 9 and 10 and BMI over 27 kg/m2. She added that education, for both the patient and entire medical team, is integral to successful SGLT use and mitigating and managing DKA.

  • Calling himself “devil’s advocate,” Dr. Simeon Taylor wrapped the session with a discussion on the potential pitfalls of SGLT inhibitor use, specifically focusing on side effects’ proliferation from early SGLT use. While the drug class has shown an attractive clinical profile in patients with type 2 diabetes, Dr. Taylor cautions that these benefits may not fully extend to patients with type 1. SGLT2 inhibitors have only shown modest decreases in A1c and weight - this, coupled with a 5.8-fold increase in DKA and subsequent risk of death, should make practitioners wary on their benefit in younger populations. SGLT2 use even showed waning glycemic efficacy patients with type 2 in CANVAS, burgeoning the question if the drug could control blood glucose beyond five years if therapy were to start in childhood. Individual variation in response to SGLT2s has also not been studied sufficiently. This combined with genital infections, DKA, accelerated loss of bone mineral density, and increased risk of bone fracture and amputations may not be worth somewhat increased blood glucose control. Dr. Taylor went so far as to call the SGLT2 inhibitor sotagliflozin ten times riskier than troglitazone, an agent taken off the market for its association to liver failure. He concluded his talk with a list of unanswered questions that should be answered before use of this drug class is considered in pediatric diabetes.

In a multi-disciplinary session spanning epidemiology, genetics, immunology, and the environment, speakers discussed novel links to type 1 and 2 diabetes. Some of the most interesting were due to environmental factors, both in a physical and sociological sense. See below for our summaries of some of the most intriguing, forward-looking presentations of the session.

  • Presenting data from a Swedish national case control study, Dr. Nina Lindell posited the association between size for gestational age and type 1 diabetes. Results found that large size for gestational age increases a child’s risk of developing type 1, while small size for gestational age decreases the risk. After controlling for maternal BMI and diabetes, being born at a large size for gestational age was determined to be an independent risk factor for type 1 diabetes. These findings derived from data from the SWEDIABKIDS registry and the Swedish Medical Birth Register emphasize the importance of prevention to reduce risk factors, like maternal weight and diabetes status, associated with large size for gestational age. Specifically, children born to mothers who were either overweight or obese during pregnancy were at an increased risk for developing type 1 (OR: 1.07, 95% CI: 1.00 – 1.14; OR: 1.22, 95% CI: 1.11 – 1.34). Maternal diabetes status was the strongest risk factor for children developing type 1 diabetes (OR: 3.34, 95% CI: 2.77 – 4.03).

  • Moving to the effects of the outdoor environment, Dr. Kate Miller presented data that link low 25-hydroxyvitamin D to increased risk of type 1 diabetes, younger age of onset and more severe presentation. The study population showcased an average 34% deficiency in 25-hydroxyvitamin D. This deficiency was associated with a significantly increased risk of developing type 1 diabetes (OR: 6.4, p<0.001). When results were stratified by sex, boys showed a linear pattern with age of type 1 diabetes onset: onset was delayed ~two years for every doubling of vitamin D level. Overall, vitamin D deficiency was associated with a mean 5.4 years earlier diabetes onset and being 4 times more likely to present with DKA. In Q&A, one audience member brought up the relevance of measuring vitamin D binding protein levels instead of free vitamin D alone to paint a more accurate picture of metabolic processes. In response, Dr. Miller mentioned that the next iteration of this study will focus on polymorphisms and genetic influences to attempt to target binding proteins.

  • To look into the lives of children with diabetes, Dr. Niels Skipper presented data on the association of prodromal type 1 diabetes with school absenteeism. The mean age of onset of the Danish sample was at 10.9 years old. While peers without type 1 averaged 1 absence a month, children with diabetes began being increasingly absent from school ~four months before diagnosis onward. Specifically, children with diabetes were absent 20% more often than their counterparts without diabetes four months before diagnosis. Peak in absences occurred right at diagnosis (50% more absent), which Dr. Skipper attributed to likely hospitalization associated with diabetes diagnosis. After onset of diabetes, children with less glycemic control were significantly 40-50% more absent than 6-12 months before onset. There was no difference in school attendance in children who had DKA, other than in the month of diagnosis. Though these trends are just correlational at this point, it’s possible that school absenteeism may be a marker for increased intervention in supporting diabetes management.

 

--by Albert Cai, Ursula Biba, and Kelly Close