ISPAD guideline updates: Insulin delivery, psychological care, nutrition and more
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The 2022 International Society for Pediatric and Adolescent Diabetes guidelines include updates on insulin delivery, psychological care and nutritional management for children, adolescents and young people with diabetes.
The updates, published as three articles in Pediatric Diabetes, revise the inaugural guidelines published in 2018 with new recommendations specific to diabetes technology and insulin delivery; psychological care of those with type 1 or type 2 diabetes; and diet content, food security assessment, insulin prescribing and dose adjustment by dietitians and continuous glucose monitoring as a tool for behavioral change.
“Clinicians must seek methods to remain abreast of new technology developments to optimize uptake and use. Integration of technology into clinical care will also require understanding of the cost-benefit of therapies to justify payer coverage,” Jennifer L. Sherr, MD, PhD, professor in the department of pediatrics at the Yale School of Medicine at Yale University, and colleagues wrote. “Indeed, as many of these technologies are expensive, further understanding of the health economics and relevant policies/regulations will provide valuable information for people with diabetes, clinicians, as well as payers.”
Insulin delivery updates
Since the first ISPAD Clinical Practice Guidelines on diabetes technology published in 2018, the guidelines have been divided into two segments — Diabetes Technologies: Glucose Monitoring; and Diabetes Technologies: Insulin Delivery. Within this update specifically on insulin delivery, authors designed the following recommendations:
- Youths should be offered the most advanced insulin delivery technology available, affordable and appropriate for them.
- Connected insulin pens may improve diabetes management for those on intensive insulin therapy with multiple daily injections and may be offered to those interested who prefer not to use an on-body device.
- Continuous subcutaneous insulin infusion therapy should be offered to youths regardless of age.
- Insulin pump therapy is safe and effective for youths with type 1 diabetes to achieve glycemic targets, reduce hypoglycemic episodes and reduce diabetes complications.
- Sensor-augmented pump therapy is superior to multiple daily injections with self-monitoring of blood glucose to reduce HbA1c without increasing hypoglycemia or severe hypoglycemia. The sensor must be used at least 60% of the time.
- Low-glucose suspend systems reduce the severity and duration of hypoglycemia without adversely affecting HbA1c.
- Predictive low-glucose suspend systems can increase confidence and trust in technology, flexibility around mealtimes and reduce diabetes distress.
- Predictive low-glucose suspend systems for type 1 diabetes should be offered if automated insulin delivery systems are unavailable.
- Automated insulin delivery systems improve time in range by minimizing hypoglycemia and hyperglycemia and help youths with type 1 diabetes meet glucose targets.
- Care providers should support people with diabetes who choose to use open-source AID systems.
- A standardized training approach should be used when new insulin delivery devices are integrated into care and counseling offered for youths and caregivers on realistic expectations for outcomes and effort needed for successful insulin pump technology use.
“Just as our everyday lives have vastly changed with integration of new technologies, including computers, smartphones and the increased connectivity of devices, the technological revolution has had an enormous effect on the management of diabetes and especially modes of insulin delivery,” Sherr and colleagues wrote. “It is reasonable to expect that in the years ahead there will be significant growth in this aspect of diabetes care and that these mechanical solutions will afford people with diabetes, and their families, improved ability to attain glycemic targets while reducing the burden of diabetes care.”
Psychological care
Other updates focus on interactions between biology, psychology and social factors for children and young adults with diabetes. The authors designed the following recommendations based on studies on stress, resilience and coping, psychological and psychiatric problems, neurocognitive functioning and integration of psychosocial assessments:
- Physicians should integrate psychosocial care with collaborative, person-centered medical care for youths with diabetes.
- Professionals with mental health expertise are essential interdisciplinary team members and should have training in diabetes to support the diabetes team in recognizing and managing mental health and behavior problems.
- Psychosocial well-being and quality of life should be assessed with age-appropriate and validated assessment tools, including screening for depression, diabetes distress and disordered eating, at the initial visit, periodic intervals and when changes in disease, treatment or life occur.
- Physicians should monitor cognitive capacity and school functioning for children younger than 7 years and those with substantial dysglycemia at diagnosis, recurrent severe hypoglycemia and/or severe hyperglycemia.
- General family functioning and diabetes-related functioning should be assessed by the interdisciplinary team, especially during periods of transition and when there are cultural or family-based difficulties in diabetes adjustment.
- Adolescents should assume increasing responsibility for diabetes management tasks, and providers need to navigate the shift in responsibilities from parents to their children.
- Technological advances in insulin delivery and glucose monitoring should be available for all youths with type 1 diabetes and be tailored to individual needs.
- The interdisciplinary team should provide preventive interventions at key developmental times, especially after diagnosis and before adolescence, emphasizing appropriate family involvement and support and realistic expectations.
- Evidence-based psychosocial, behavioral or psychiatric interventions should be available along with collaborative care for youths or families experiencing conflict, disordered communication, diabetes distress, or behavioral or psychiatric difficulties.
According to the authors, future research should assess which key intervention components may be attributed to positive diabetes outcomes and match psychological approaches to the life course. In addition, more studies specifically targeting youths with type 2 diabetes and young adults are required.
“There are also opportunities for more research using clinic-based brief interventions during routine care that focus on improved self-management and reduction of diabetes distress, which could have the potential to maximize reach and impact through scalability,” Maartje de Wit, PhD, researcher from the division of medical psychology at the Amsterdam University Medical Center, and colleagues wrote.
Nutritional management
Finally, there was also a focus on nutritional advice for young adults aged 18 to 24 years based on the adult nutrition recommendations. The authors have designed the following recommendations targeting healthy eating principles, glycemic management, cardiovascular disease risk factors, maintenance of psychosocial well-being and family dynamics:
- Nutrition therapy should be used and advice adapted to cultural, ethnic and family traditions as well as the cognitive and psychosocial circumstances.
- Individualized meal plans should be implemented with prandial insulin adjustments to improve outcomes. Dietary recommendations should be based on healthy eating principles to improve diabetes outcomes and reduce CVD risk.
- Specialist dietitians with experience in pediatric diabetes should be part of the multidisciplinary team and available at diagnosis to develop a consistent relationship.
- Energy intake and essential nutrients should aim to maintain ideal body weight, optimal growth and development and to help prevent acute and chronic complications.
- Insulin dose should be matched to carbohydrate intake on intensive insulin regimens to allow greater flexibility in carbohydrate intake and mealtimes with improved glycemia and quality of life.
- Fixed insulin regimens requiring consistency in carbohydrate amount and timing should be used for optimal targets and to reduce hypoglycemia risk, but preprandial insulin dosing should be encouraged from diabetes onset for youths of all ages..
- Glycemic index provides additional benefit to glycemic management.
- Youths should be offered advice to prevent overweight and obesity based on a family-oriented approach. Nutritional advice should include successfully managing regular and unanticipated physical activity and how to meet individual goals in competitive sports.
“Evidence suggests that it is possible to improve diabetes outcomes through attention to nutritional management and an individualized approach to education. This requires a clear focus on dietary goals in relation to glycemic outcomes and reduction in CVD risk,” S. Francesca Annan, BA, MA, clinical specialist in pediatric and adolescent diabetes and dietitian in the pediatric division at the University College London Hospital, and colleagues wrote. “The foundation of successful dietary outcomes is the development of a trusting relationship between the child/adolescent and care providers, which facilitates behavioral change during the challenges of childhood and adolescent development.”
References:
- de Wit M, et al. Pediatr Diabetes. 2022;doi:10.1111/pedi.13428.
- Annan SF, et al. Pediatr Diabetes. 2022;doi;10.1111/pedi.13429.
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