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blood glucose monitoring system

Patterns of continuous glucose monitoring use in young children after T1D diagnosis

blood glucose monitoring system

The findings suggest that, when clinically appropriate, continuous glucose monitoring initiation near or at the time of diagnosis benefits glycemic outcomes in young children when followed by sustained use.

Continuous glucose monitoring (CGM) is a blood glucose monitoring device worn on the body that is linked to positive glycemic outcomes in people with Type 1 diabetes (T1D). However, very little research has examined CGM use and glycemic outcomes in young children, particularly those newly diagnosed with T1D.

A new Diabetes Technology and Therapeutics study led by Randi Streisand, Ph.D., C.D.C.E.S., Chief of Psychology and Behavioral Health at Children’s National Hospital, and others identified four meaningful trajectories of CGM use among young children across 18-months post-T1D diagnosis: those who “always” used CGM; those who got on CGM later but stayed on it (“late/stable”); those who used CGM inconsistently; and those who “never” used CGM. The investigators conducted a study of 157 parents of young children (1-6 years) newly diagnosed with T1D who enrolled in a behavioral intervention.

Importantly, the authors found that those with private insurance were more likely than those with only public insurance to be in the “always” and “late/stable” groups (as opposed to the “never” group). Those in the “always” and “late/stable” groups also had better glycemic outcomes than those in the “never group” at 18-months post-T1D diagnosis.

“This research highlights that insurance type can be a barrier to accessing CGM,” Dr. Streisand noted. “Further, this is one of the first studies, among newly diagnosed young children, to show that CGM initiation at diagnosis or near diagnosis followed by sustained use is associated with better glycemic outcomes compared to never initiating CGM, supporting findings from other studies conducted with older youth.”

The findings inform clinical care with patients as it suggests that, when clinically appropriate, CGM initiation near or at the time of diagnosis benefits glycemic outcomes in young children when followed by sustained use. This is the only study to examine patterns of CGM use among 1-6-year-old children newly diagnosed with T1D over the first 18-months post-diagnosis.

“It was exciting to find differences in glycemic outcomes based on CGM initiation and use in this unique population,” Dr. Streisand said. However, the authors concluded that, given the health benefits of CGM, further exploration of barriers to CGM access and use among some families is needed.

In addition to Dr. Streisand, other Children’s National co-authors include Brynn Marks, M.D., M.S. HPEd.; Carrie Tully, Ph.D.Maureen Monaghan, Ph.D., C.D.E. , and Christine Wang, Ph.D.

boy checking his blood glucose

There’s still more to learn about COVID-19 and diabetes

boy checking his blood glucose

Researchers have learned a lot about COVID-19 over the past year and are continuing to learn and study more about this infection caused by the SARS-CoV-2 virus. There have been many questions about whether COVID-19 affects people with diabetes differently than those without and why this might occur.

Diabetes experts, like Brynn Marks, M.D., M.S.H.P.Ed., endocrinologist at Children’s National Hospital, have been studying the relationship between COVID-19 and diabetes, especially in the pediatric population. Dr. Marks tells us more about what we know so far and further research that needs to be done when it comes to COVID-19 and diabetes.

1.      What do we know about COVID-19 and its effect on people with known diabetes?

The Centers for Disease Control and Prevention (CDC) currently lists type 2 diabetes (T2D) as a high risk condition for severe illness related to COVID-19 infection, while stating that adults with type 1 diabetes (T1D) might be at increased risk. A recent study from Vanderbilt University found that people with T1D and T2D were at approximately equal risk for complications of COVID-19 infection. As compared to adults without diabetes, adults with T1D and T2D were 3-4 times more likely to be hospitalized and to have greater illness severity. Given these comparable risks, both the American Diabetes Association and the Juvenile Diabetes Research Foundation are lobbying for adults with T1D to be given the same level or priority for COVID-19 vaccines as adults with T2D.

However, as pediatricians, we all know to be wary of extrapolating adult data to pediatrics. Children are less likely to be infected with COVID-19 and if they are, the clinical course is typically mild. To date, there have not been any studies of the impact of COVID-19 on youth with known T2D. Our clinical experience at Children’s National Hospital and reports from international multicenter studies indicate that youth with T1D are not at increased risk for hospitalization from COVID-19 infection. However, paralleling ongoing disparities in T1D care, African Americans with known T1D and COVID-19 infection were more likely to be develop diabetic ketoacidosis (DKA) than their White counterparts.

With the increased use of diabetes technologies, including continuous glucose monitors, insulin pumps and automated insulin delivery systems, diabetes care lends itself well to telemedicine. Studies from Italy during the period of lockdown showed better glycemic control among youth with T1D. Further studies are needed to better understand the implications of telehealth on diabetes care, particularly among those in rural areas with limited access to care.

Brynn Marks

Diabetes experts, like Brynn Marks, M.D., M.S.H.P.Ed., endocrinologist at Children’s National Hospital, have been studying the relationship between COVID-19 and diabetes, especially in the pediatric population.

2.      What do we know about the impact of the COVID-19 pandemic on children with newly diagnosed diabetes?

Nationwide studies from Italy and Germany over the first few months of the pandemic found no increase in the incidence of pediatric T1D during the COVID-19 pandemic as compared to the year before; in fact, the Italian study found that fewer children were diagnosed with T1D during the pandemic. However, many centers are seeing higher rates of DKA and more severe DKA at diagnosis during the pandemic, possibly due to decreased primary care visits and/or fears of contracting COVID-19 while seeking care.

To date, no studies have been published exploring the incidence of T2D in youth. A group from Children’s National, including myself, Myrto Flokas, M.D., Abby Meyers, M.D., and Elizabeth Estrada, M.D., from the Division of Endocrinology and Randi Streisand, Ph.D., C.D.C.E.S. and Maureen Monaghan, Ph.D., C.D.C.E.S., from the Department of Psychology and Behavioral Health, are gathering data to compare the incidence of T1D and T2D during the pandemic as compared to the year before.

3.      Can COVID-19 cause diabetes to develop?

This has been area of great interest, but the jury is still out. The SARS-CoV-2 virus, which causes COVID-19 infection, binds the angiotensin-converting enzyme 2 (ACE2) receptor which is located in many tissues throughout the body, including the pancreas. SARS-CoV-2 has been shown to infect pancreatic tissue leading to impaired glucose stimulated insulin secretion. Although the SARS-CoV-2 virus could plausibly cause diabetes, assessment has been complicated by many confounders that could be contributing to hyperglycemia in addition to or rather than the virus itself. Stress-induced hyperglycemia from acute illness, the use of high dose steroids to treat COVID-19 infection, and the disproportionate rates of infection among those already at high risk for T2D, as well as weight gain due to changes in day-to-day life as a result of social distancing precautions are all likely contributing factors.

Randi Streisand

Randi Streisand, Ph.D., receives 2020 Richard R. Rubin Award

Randi Streisand

Randi Streisand, Ph.D., is the recipient of the 2020 Richard R. Rubin Award. This national award, sponsored by the American Diabetes Association, recognizes a scientist who has made outstanding, innovative contributions to the study and understanding of the behavioral aspects of diabetes.

Currently, Dr. Streisand is a tenured professor of psychology and pediatrics at The George Washington University School of Medicine and serves as chief of the Division of Psychology & Behavioral Health at Children’s National Hospital. Additionally, she serves as vice-chair for the Institutional Review Board, and provides clinical services for families impacted by diabetes and other health conditions. She is also an active mentor and educator for trainees and early career faculty members regarding research and clinical service.

Throughout her career, Dr. Streisand has received multiple research and training grants, published approximately 100 papers in peer-reviewed journals, and presented at national and international meetings. She has also been recognized for her mentorship and received awards from Children’s National as well as the Society of Pediatric Psychology. Dr. Streisand’s research is funded by the National Institutes of Health (NIH) and focuses on parent-child adjustment to diabetes, and behavioral interventions to promote adjustment, adherence and glycemic control. Her research has included young children through teenagers, and she is currently evaluating the use of a parent coach program to support parents of young children newly diagnosed with type 1 diabetes.

Dr. Streisand has served on several editorial boards for journals, serves as a grant reviewer for NIH, and has served in elected positions for professional organizations. She is also a Certified Diabetes Educator.

Randi Streisand

Randi Streisand, Ph.D. to be honored with the Michael C. Roberts Award for Outstanding Mentorship

Randi Streisand

Randi Streisand, Ph.D., chief of Psychology and Behavioral Health at Children’s National Health System, will be honored with the Michael C. Roberts Award for Outstanding Mentorship by the  Society of Pediatric Psychology (SPP), a Division of the American Psychological Association. This award honors pediatric psychology faculty who go above and beyond to mentor students and provide professional advice and guidance through students’ various training phases.

The Society of Pediatric Psychology will present the award at their Annual Conference held on Apr. 4-6, 2019 in New Orleans, La.

Streisand was selected for the award based on her exceptional mentorship in the areas of research, clinical work and overall career development through graduate school, postdoctoral fellowships and early career stages.

“I’m very honored to be selected for this distinguished award,” says Streisand. “Working with students, fellows and junior faculty members has been the highlight of my career. I really enjoy helping guide people on their own career paths. I have been fortunate to mentor many truly talented individuals, several of whom I now get to work with as valued colleagues.”

Streisand has served as a primary mentor on funded career development awards, research fellowships and dissertations. Her impressive track record of mentoring behavioral researchers has benefited six faculty members by moving Children’s fellows into tenure-track and clinical faculty positions. Furthermore, her research assistants have been accepted into leading graduate programs in psychology and health including the University of Florida, Loyola University Chicago, Georgia State University and UT Southwestern Medical Center.

“Dr. Streisand’s approach to mentorship is comprehensive, and she goes the extra mile for each intern, colleague and researcher she works with,” says Roger J. Packer, M.D., senior vice president at Children’s Center of Neuroscience and Behavioral Medicine. “She has already made a major impact on the field of pediatric psychology through her superb mentorship and will continue to do so for the years to come.”

Randi Streisand

Randi Streisand, Ph.D., appointed Chief of Psychology and Behavioral Health at Children’s National Health System

Randi Streisand

Children’s National Health System announces that Randi Streisand, Ph.D., will become the chief of Psychology and Behavioral Health within the Center for Neuroscience and Behavioral Medicine. Dr. Streisand is a behavioral scientist, child health researcher and certified diabetes educator. She is a tenured professor of Psychology and Behavioral Health, and Pediatrics at The George Washington University School of Medicine and Health Sciences, and serves as the director of Psychology Research for Children’s National Health System.

“Dr. Streisand’s acceptance of this leadership position will play an integral role in our approach to improve research methods and providing comprehensive approaches to psychological treatments” says Roger J. Packer, M.D., senior vice president of the Center for Neuroscience and Behavioral Medicine.

As chief, Dr. Streisand will lead our team of nationally recognized educators, research leaders and specialists who are experts in the care of children and teens with emotional and behavioral disorders. She will also continue to lead an extensive research portfolio, focusing on parent-child adjustment to chronic disease, behavioral interventions to prevent and control disease and treatment complications and adherence to pediatric medical regimens.

Before joining the faculty at Children’s National in 2000, Dr. Streisand received her doctorate in clinical psychology from the University of Florida, completed her internship at Brown University and a fellowship at the Children’s Hospital of Philadelphia. She has written numerous publications in the areas of child health and serves on several grant review committees through Children’s National, NIH and the American Diabetes Association. At Children’s National, she is an active participant in the psychology training program, and mentors undergraduates, graduate students, interns, fellows and junior faculty members.

asthma inhailer

A successful patient-centered asthma study

A study by Stephen Teach, M.D., M.P.H., shows that extensively engaging stakeholders such as parents, families and local service providers in study design can transform a planned research project into a more patient-centered study.

For hundreds of years, scientific and medical research has followed a process that practically all grade-school children learn as the scientific method: Scientists make observations that lead to a question. After developing a hypothesis, the researchers and colleagues — usually other scientists in the same field — test it by gathering data from experiments, making more observations or searching through the existing literature. Once they have an answer, the researchers often publish it in a scientific journal, which can generate new questions among peer scientists and starts the cycle all over again.

While most research is meant to benefit humankind as a whole, non-scientists and people who aren’t research subjects usually aren’t involved much in the process itself. That can be a serious omission, particularly for medical research, says Stephen J. Teach, M.D., M.P.H., chair of the Department of Pediatrics at Children’s National Health System, and Deborah Quint Shelef, M.P.H., C.C.R.P., AE-C., program director at IMPACT DC, a program at Children’s National Health System that helps patients effectively manage asthma.

“Our patients might view research a little differently than we do. They don’t just want general contributions to knowledge, but specific contributions that people can actually use,” Shelef says. “One of our main goals is to have useful research models that can translate into changes that really improve patient care. It’s hard to make this happen without asking people who are affected most what would address their needs.”

That’s why Shelef and Dr. Teach’s most recent study, featured on the cover of the December 2016 issue of The Journal of Allergy and Clinical Immunology, shifts the research paradigm from a scientist-centered model to what they call a stakeholder-centered approach. Rather than develop the study solely with fellow researchers, the research team led by Children’s National relied heavily on guidance from people who would be most impacted by the results.

The study focused on whether an intervention that reduced parental stress could improve asthma outcomes among low-income African American children. To help design their study, the research team looked to several different sources for advice: African American parents of children treated for asthma at Children’s National; local providers of social, medical, legal and educational services; and experts in psychosocial stress, medication adherence and conducting studies among at-risk youth with asthma.

The researchers gave themselves one year to consult multiple times with each stakeholder group before starting to enroll study subjects in May 2015. In the initial planning phases, the research team intended to focus their study on whether reducing parental stress would change how well children stuck to taking their asthma medications. However, that focus quickly changed, says Shelef. “Medication adherence just wasn’t a meaningful goal to most parents,” she explains. “To them, having more symptom-free days was a better gauge of how well an intervention was working for their children.”

The proposed intervention itself also transformed. Rather than focusing on problem-solving, cognitive-reframing and parenting skills — the researchers’ initial ideas — the final intervention would instead teach participants mindfulness, deep breathing, positive thinking, self-care and gratitude — as well as how to use these coping skills with their children. Rather than being staffed by social workers or psychologists, the stakeholders preferred people they felt they could relate to: Community wellness coaches with experience teaching yoga, meditation or other wellness activities in neighborhoods in which they lived.

Several other tweaks significantly changed the study from its early incarnation into the final version that the researchers are currently implementing, says Dr. Teach. “We ended up in a very different place from where we started based on this extensive process of stakeholder engagement,” he says.

Shelef notes that it’s not always feasible to involve stakeholders so heavily or to intensively plan a study for a year before it begins. Keeping all the advisers focused on the study at hand without radically changing the focus was a challenge, she says, and it was an “incredible scramble” in the end to translate all of their feedback into a cohesive product. However, having input from the people who could gain the most from the research results made it all worth it.

“The real benefit to this approach is the richness of the final product,” Shelef says. “Ultimately, this study will show a lot more than if we hadn’t put so much into it at the beginning.”