was linked to HbA1c >9.0% and insulin nonadherence. These findings demonstrate the importance of screening for a variety of psychosocial concerns with referrals for psychological support. Healthcare Consideration : Children and adolescents with T1DM may have psychosocial concerns, which can create barriers to successful glycemic control. These include anxiety, depression, disordered eating, and family conflict (Brodar et al., 2021). Routine and standardized psychosocial screening is essential for identification of these barriers. A recent study evaluated a screening program for these concerns and noted a 24.9% increase in psychological consultations 10 months postimplementation (Brodar et al., 2021). In pediatric patients with diabetes, the high prevalence of depression and anxiety may contribute to or coexist with disordered eating behaviors (Buchberger et al., 2016; Salah et al., 2022). Eating disorders and disordered eating symptoms are collectively more prevalent in the T1DM population than the general population. Other identified risk factors include female gender, higher body mass index, body dissatisfaction, and poor attention in family to healthy eating. Unhealthy eating behaviors are correlated with worsened glycemic control and increased rates of diabetes-related complications, including premature death (Toni et al., 2017). Patients with bulimia nervosa and binge-eating disorder were even found to have higher risk of retinopathy. Carbohydrate counting may heighten a fixation on food intake, and precision in food proportion is an identified risk factor for the development of an eating disorder. Furthermore, intentional withholding of exogenous insulin may result in weight loss. Many adolescents discover this and utilize this tactic as a form of weight control, which worsens hyperglycemia and diabetes-related outcomes. The prevalence of disordered eating in adolescents is typically established through dialogue and patient questionnaires. While these methods may be incorporated into clinical practice, there are also a few objective signs that may indicate the presence of a possible eating disorder. These include higher mean HbA1c, recurrent hypoglycemic episodes, and refusal to be weighed. Of course, there are other explanations for these observed signs, but it is prudent to consider attribution to an eating disorder, especially in adolescents. Interventions for prevention and treatment of disordered eating include provision of mental health services and frequent follow-up with family support. The approach should be multidisciplinary, including a pediatric dietician and psychologist (Toni et al., 2017). Since depression and anxiety can underlie disordered eating, psychiatric intervention for these illnesses may also benefit eating habits. Nutritional counseling is a key component of successful therapy, and family should be included in developing healthy behaviors at home. Interestingly, a recent study identified a higher rate of disordered eating behavior in
adolescents maintained on basal–bolus regimens than those on CSII (Salah et al., 2022). Although the study was small, new technology may be a promising intervention to prevent or treat disordered eating. Evidence-based practice! Mindfulness-based interventions, including “body scans,” yoga postures, and meditations, demonstrate effectiveness in a variety of chronic illnesses (Inverso et al., 2022). Although data are limited, mindfulness- based interventions may reduce depression and stress in adolescents with diabetes. Attempted suicide and suicidal ideations are reported at an increased rate in adolescents and young adults with diabetes compared to the nondiabetic population (Hill et al., 2021). This is theorized to be related to several factors. One is feeling like a burden to family in regard to time and money spent on the diagnosis. Adolescents with T1DM also report feeling isolated due to poor social support. In addition, management of diabetes involves repeated painful tasks, including glucose checks and insulin injections. Taken together, these factors indicate a higher risk of suicide attempt and ideation. Particularly concerning in this population, insulin may be used for suicide attempt if administered at high doses. Easy access to lethal medication is worrisome in such a vulnerable population and may contribute to increased risk of harm. Providers should be educated about this risk as well as the warning signs and tools for screening. Identifying stressful aspects of diabetes care may help elucidate areas for intervention to decrease the burden of the diagnosis. Examples include switching to lower cost medications, prescribing an insulin pump to minimize injections, and implementing a CGM to reduce risk of hypoglycemia. Families should also be educated and can participate in supporting the adolescent while ensuring safe storage of firearms and other lethal devices. Self-Assessment Quiz Question #8 Lucy is demonstrating worrisome signs of disordered eating behaviors. All of the following are effective methods of intervening for diabetes-related disordered eating issues EXCEPT: a. Switching from a basal–bolus insulin regimen to continuous subcutaneous insulin infusion therapy. b. Referring the patient to a psychologist or psychiatrist for further evaluation. c. Assessing for depression and anxiety symptoms underlying the disordered eating. d. Recommending she create a detailed log of all her food intake.
TYPE 1 DIABETES MELLITUS: FUTURE DIRECTIONS
In November 2022, the first immunomodulatory treatment to delay progression of stage 2 T1DM to stage 3 T1DM was approved for use in pediatric patients ages 8 years and older (Lexicomp, 2022). In a clinical trial of 76 patients with stage 2 T1DM, patients who received teplizumab-mzwv, an anti-CD3 monoclonal antibody, demonstrated a 50-month median delay in clinical T1DM compared to a 25-month delay in those that received placebo (U.S. Food and Drug Administration, 2022). In the study, teplizumab was given as a once daily intravenous infusion for 14 days, and the most common adverse reactions were lymphopenia, leukopenia, rash, and headache. Real-world safety and efficacy data are anticipated in the upcoming months to years for this promising intervention. As technology and medicine advance, novel methods of controlling T1DM are being developed. These methods are aimed at more closely mimicking normal functioning of the pancreas. As previously outlined, automated insulin delivery
systems pair insulin pumps with CGM devices (ADA et al., 2022c). This technology has the capability to suspend insulin delivery in response to low blood glucose and increase insulin delivery in response to high blood glucose. Although some aspects of this technology are automated, the pumps still require manual entry of carbohydrates consumed during meals. Through more advanced algorithms, newer systems reduce the need for user interaction. A new automated insulin delivery system was recently studied in children and adolescents ages 6 to 17 years (Messer et al., 2022). This system, referred to as a bionic pancreas, only requires input of user body weight, and all insulin doses are determined algorithmically. Meals and large snacks require input signals to the bionic pancreas; however, this is accomplished without the need for carbohydrate counting. Users must only input if the meal is “usual for me,” “more,” or “less” carbohydrates compared to their typical meals. In response to this input, the bionic pancreas delivers 75% of the estimated need and then adjusts after the meal is consumed based on
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