Diabetes Technology in T1D Youth & Pediatrics Used for Glucose Control and Obesity

In the SWEET project experience, a large cohort of patients was started on either an insulin pump, glucose sensor, or both to compare the HbA1c levels and weight gain while on their new therapy.

Many health complications can arise from diabetes, especially for adolescents and children with type 1 diabetes, where weight gain is an increasing issue. The very medication that this population takes for their diabetes has been suggested by research to increase their fat accumulation, although they achieve greater levels of glycemic control. Diabetes technology (continuous glucose monitoring systems [CGM] and insulin pumps) can help with adherence and allow for a more flexible daily regimen because there isn’t a need for the child to adjust the regimen themself. Although these are benefits of using the diabetes technology, a concern is its impact on the body composition of this population. Since studies are sparse in this area, the SWEET project was designed to associate this technology with HbA1c and body mass index (BMI) over time in patients who have not used this form of insulin technology before. Research has suggested that using more intense or flexible insulin regimens has increased fat accumulation. According to The Diabetes Control and Complications Trial (DCCT), the benefits of using intensive insulin therapy decrease significant heart, microvascular, and macrovascular complications.

This study is a prospective (over time) international cohort of children and adolescents who have never used this technology to improve best practices for clinicians and outcomes for this population. Included in the study were patients 2-18 years of age with T1D for more than one year with no celiac disease. In addition, those who have used some form of diabetes technology with no reports of imperative information (age, gender, HbA1c, BMI, duration of diabetes) were excluded. The data sets were collected in 2016 and 2019, with an initial 77,254 patients down to 4,643 patients. Nine groups were formed using insulin therapy, and multivariable (linear) regression models were used. Other statistical analyses used were the Wilcoxon Rank Sum Test, McNemar Test, medians, interquartile ranges, and Bonferroni step-down method for the various types of data presented.

With a total of 4643 patients (52% male), statistical significance was found in the areas of increased BMI and worsening metabolic control (HbA1c) with p values <0.001. The amount of insulin (in IU) and the addition or change of diabetes technology increased within the collected data set with a p-value of <0.001. The results analyzed those who changed their technology versus those who stayed with the same one over time. Overall, those that did not change their devices had no statistically significant changes in BMI or HbA1c; however, when comparing these groups to others with no change in devices, there was a statistical difference in median HbA1c and BMI. Those who switched from multiple daily injections (MDI) to an insulin pump and patients with insulin pumps who added CGM had improved HbA1c and improved glucose control, respectively. BMI was worse over the three years in those who switched from MDI to an insulin pump.

With the increasing trend of weight gain and increased BMI in the youth, this study utilized a database to compare the effect on BMI and HbA1c levels over three years depending on the diabetes device. There is still room for growth for these devices, and availability depends on many socioeconomic factors. Data has shown some possible reasons for increased adiposity and poorer glucose control in this population. Intensive insulin treatments (multiple daily shots) cause more hypoglycemia, so there is a greater need for carbohydrates to prevent this from happening, leading to weight gain. Once the child reaches adolescence, this can lead to worsening metabolic control. Access to education has proven beneficial to their glucose control, especially if the patient is going to be started on some form of diabetes technology. Although this study followed the population over three years, the record from when they started or added the new technology was unknown. Another limitation is the BMI for measuring fatness, although typically used in healthcare. Diet was not monitored, which can significantly impact HbA1c and BMI, especially if the patient continues to eat excess calories while increasing their insulin dose. The socioeconomic disparities, diet, and physical activity can impact the results and should be included in future studies. Overall, additional studies would be beneficial and an increase in accessibility for diabetes and health education in this population.

Practice Pearls:

• Continuous subcutaneous insulin is an effective way to treat children and adolescents with T1D.
• Fat accumulation in children and adolescents with type 1 diabetes was seen in those who switched to an insulin pump.
• Benefits of using intensive insulin therapy are a decrease in significant heart, microvascular, and macrovascular complications.

Marigliano, Marco et al. “Association of the use of diabetes technology with HbA1c and BMI-SDS in an international cohort of children and adolescents with type 1 diabetes: The SWEET project experience.” Pediatric diabetes vol. 22,8 (2021): 1120-1128. doi:10.1111/pedi.13274 [https://pubmed-ncbi-nlm-nih-gov.ezproxy.hsc.usf.edu/34716736/]

Megan Jane, PharmD Candidate 2022, USF Taneja College of Pharmacy