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Diabetes technology and the human factor

2012; Wiley; Volume: 66; Linguagem: Inglês

10.1111/j.1742-1241.2011.02858.x

1742-1241

Alon Liberman, Bruce A. Buckingham, Moshe Phillip,

Diabetes and associated disorders

The task of preserving the desired glucose control is challenging for both patients with type 1 diabetes mellitus (T1D) and their families. Having a chronic disease with a demanding treatment regimen means the person with diabetes must maintain a high level of motivation and adherence without having the opportunity to take a 'vacation' from their diabetes. Recent developments in diabetes technologies improved diabetes control, but were associated with the need to wear more devices and pay increased attention to the disease. At the present time using the new technologies still requires treatment decisions which remain the ultimate responsibility of the patient. In other words, the 'human factor' in diabetes technologies is still mandatory and therefore must be taken into consideration. The 'human factor' is not a single issue; it encompasses physical and emotional and intellectual interfaces, understanding new information, as well as the 'hassle factor' of the different devices. For some patients the advantages of the new technologies such as insulin pumps, glucose sensors and self-monitoring of blood glucose (SMBG) levels are outweighed by the perceived burdens and hassles imposed by these tools. In addition, there are unique concerns for specific groups such as skin real-estate issues with young children, fear of hypoglycaemia in both parents of young children and adult patients, behavioural issues associated with identity development in adolescents (fear of being 'different') as well as the usual problems of stress, anxiety and depression which are common even in the population without diabetes. Finally, problems concerning decreased adherence, lack of motivation and low quality of life can significantly affect the 'human factor'. The present chapter will review papers published in the last year that examined some of these issues. O'Connell MA 1 , Donath S 2 , Cameron FJ 1 1 Department of Endocrinology and Diabetes, Royal Children's Hospital and Murdoch Children's Research Institute, Melbourne, Australia, and 2 Clinical Epidemiology and Biostatistics Unit, Royal Children's Hospital and Murdoch Children's Research Institute, Melbourne, Australia Pediatric Diabetes 2011: 12 : 556–9 Background: Utilising continuous subcutaneous insulin infusion (CSII) regimens helps many young people improve their glycaemic control; however, there is still a significant proportion of patients who do not have sustained good glycaemic control. The purpose of this study was to evaluate adherence to recommended CSII-associated tasks in a paediatric cohort (mean age 13 years) and to recognise potentially modifiable behaviours that affect their HbA1c level. Methods: CSII data from 100 youth with T1D were uploaded and analysed using CareLink Software (Medtronic Minimed). Results: In their study mean bolus frequency was 6.1 per day; however, 69/100 entered fewer than four blood glucose levels per day. HbA1c decreased by 0.2% for every additional blood glucose level (p = 0.001) and bolus event (p < 0.001) per day. Prandial insulin omission was frequent and related to significant increases in HbA1c. Older age and duration of CSII were associated with poorer adherence to recommended behaviours. Conclusions: Glycaemic gain achieved by CSII regimens is closely related to the way in which CSII is utilised by the patient on a daily basis. Poor adherence to overall CSII-related tasks is frequent in adolescents and limits the efficacy of CSII in this age group. Olinder AL 1,2 , Nyhlin KT 3 , Smide B 2 1 Sachs' Children's Hospital, Södersjukhuset, Stockholm, Sweden, 2 Department of Medical Sciences, Uppsala University Hospital, Uppsala, Sweden, and 3 School of Life Sciences, University of Skövde, Skövde, Sweden Pediatric Diabetes 2011; 12 : 402–9 Background: The aim of this study was to examine the reasons for missed bolus doses and the strategies adolescents utilise for avoiding this when using insulin pumps. Methods: The authors choose grounded theory method as a model for the collecting and analysing of data. Data were obtained through interviews with 12 adolescents treated with CSII (five males and seven females, mean age 14.4 years) from different Swedish paediatric diabetes clinics. All interviews were tape-recorded and immediately transcribed. Results: The core theme of 'lost focus' came up as representing the main cause for missed bolus doses. Recognised subcategories were delayed lost focus, directly lost focus and totally lost focus. There was a hazard of delayed lost focus when youth used postprandial bolusing. Focus could also be lost directly in connection with the beginning of the meal. Totally lost focus happened when the adolescent apprehended the consequence of diabetes as too high or tried to ignore that he or she had it. The category 'agreements about reminders' appeared to be the main strategy for avoiding missed bolus doses; more subcategories were personal reminders and technical reminders. An involvement of the adolescent in these agreements was necessary; otherwise, the reminding could be seen as nagging and fail to succeed. Conclusion: The results may help diabetes care teams appreciate the circumstances in which youth miss their bolus insulin doses. This may make it easier to talk about missed doses and develop strategies for avoiding this behaviour and will enable discussions between parents and children over agreements about reminders. Comment: The problem of bolus omission in CSII management among children and youth is well known and has been documented in several previous studies. Burdick et al. (1) reported that patients who missed less than one mealtime bolus per week had a mean of 8.0% A1c compared with 8.8% for patients that missed more than one bolus per week. They concluded that 'Missed mealtime insulin boluses seem to be the major cause of suboptimal glycaemic control in youths with diabetes receiving continuous subcutaneous insulin infusion therapy'. It is the constant, unremitting daily demands of diabetes that make adherence difficult for adolescents who have many other priorities in their daily routines. Full closed-loop or treat-to-range closed-loop therapy could provide a significant benefit to this particular age group. The same frequency of missed meal boluses may also occur in patients using multiple daily injection (MDI) therapy, but we currently do not have pens with downloadable memory to allow for collection of this data. The two above-mentioned studies provide a complementary perspective on this subject. The first cross-sectional study has examined the problem from the quantitative aspect and has found that 'Maladaptive behaviours that correlated with higher HbA1c were alarmingly common'. The unwanted behaviour included infrequent SMBG and omission of breakfast bolus insulin and was found in 70% of the patients. The authors emphasise the importance of the influence of human behaviour on glycaemic outcomes with CSII and call for enforcing adherence in order for optimal balance. The second qualitative study assessed the reasons adolescents gave for missing meal boluses. According to this study, many of the patients omitted insulin boluses to avoid embarrassment around their peers or to prevent hypoglycaemia by delivering the bolus after onset of the meal. In consequence some of them postpone the insulin bolus and eventually forget it. Indeed, there are a certain number of patients who find the CSII management too overwhelming and ignore many of their insulin boluses. Missed meal boluses is a common problem that should be addressed when there are fewer than three boluses a day, or at times of the day when food is commonly consumed and there is no observed meal bolus in the pump download. Understanding the problem from the patient's point of view may help the patient feel more understood and his/her adherence to the treatment may increase. These studies also highlight the value of having good software that allows easy visualisation and documentation of insulin administration. In the CareLink software this is best observed by reviewing the 'daily details' reports with the patient. This ability to discuss daily aspects of diabetes management with concrete data is missing when patients use MDI therapy, and some pump software does not provide the same, easily assessed and visualised daily details. As we progress with additional steps to closed-loop therapy, the software should allow easy visualisation of the results to both the patient and healthcare provider. Tansey M 1 , Laffel L 2 , Cheng J 3 , Beck R 3 , Coffey J 1 , Huang E 4 , Kollman C 3 , Lawrence J 5 , Lee J 6 , Ruedy K 3 , Tamborlane W 7 , Wysocki T 8 , Xing D 3 ; on behalf of Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study Group 1 Department of Pediatrics, University of Iowa , IA, USA, 2 Joslin Diabetes Center, Pediatrics, Harvard Medical School, Boston, MA, USA, 3 Jaeb Center for Health Research, Tampa, FL, USA, 4 University of Chicago, Medicine, Chicago, IL, USA, 5 Department of Research and Epidemiology, Kaiser Permanente Southern California,Anaheim, CA, USA, 6 University of Michigan, Child Health Evaluation and Research Unit, Ann Arbor, MI, USA, 7 Yale University School of Medicine, Pediatrics, New Haven, CT, USA, and 8 Nemours Children's Clinic, Center for Pediatric Psychology Research, Jacksonville, FL, USA Diabet Med 2011; 28 : 1118–22 Aim: The purpose of this study was to describe satisfaction with continuous glucose monitoring (CGM) in T1D patients; to relate CGM satisfaction scores with usage; and to identify common themes in perceived benefits and obstacles of monitoring reported by adults, adolescents and the parents of adolescents in the Juvenile Diabetes Research Foundation (JDRF) CGM trial. Methods: The Continuous Glucose Monitoring Satisfaction Scale questionnaire was completed after 6 months of CGM use. Patients also completed open-ended queries of positive and negative attributes of CGM. Results: A relationship was found between more frequent use of CGM and higher scores of satisfaction among adults (n = 224), youths (n = 208) and parents of youths (n = 192) (all p < 0.001). This was true for both the 'benefits' and 'hassles' subscales of the Continuous Glucose Monitoring Satisfaction Scale, but the most significant differences between the two groups involved scores on hassle factors. Common obstacles to monitoring use included sensor needle pain, system alarms and body image issues; while common benefits included glucose trend data and options to self-correct out-of-range glucose levels and to detect hypoglycaemia. Conclusions: Although patients who use continuous glucose monitoring often have a better chance for increasing their glycaemic control without increasing hypoglycaemia, it is still important to overcome obstacles to consistent use, strengthen benefits and set realistic expectations for this technology. Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study Group Diabetes Care 2010; 33 : 2175–217 Background: The influence of CGM on quality of life (QOL) was examined among participants with T1D. Methods: In this multicentre trial, 451 children and adults with T1D were assigned randomly to CGM treatment or the control group. All patients and their parents (of patients younger than 18 years) completed both generic and diabetes-specific QOL questionnaires at baseline and 26 weeks and the CGM satisfaction scale was completed by the CGM group (patients and parents) at 26 weeks. Results: After 26 weeks of CGM use, QOL scores remained largely unchanged for both the treatment and the control group. However, a slight difference was documented in favour of the adult CGM group on several subscales (p < 0.05). There was substantial satisfaction with CGM technology after 26 weeks among participants and parents. Conclusions: Baseline QOL was high, and the measures showed minor changes with CGM use, although a high level of CGM satisfaction was reported. Comment: Understanding how patients perceive the benefits and barriers to CGM is important for identifying strategies to reduce barriers and enable more consistent monitoring. Several studies have recently validated the Continuous Glucose Monitoring Satisfaction Scale as an important scale that helps in assessing directly both the benefits and hassles associated with CGM use. A large JDRF trial found that adolescents did not use the CGM as much as pre-pubertal children, were less satisfied, could not accept the hassle and burden caused by CGM use and failed to achieve the study A1c targets. The first study presented above examined the relationship between frequency of CGM and its satisfaction by all users (adults, adolescents and their parents). They found that patients who used the CGM more frequently (6 days or more per week) reported more benefits and less hassles compared with infrequent users (4 days or more per week). From the self-reported information, interesting discrepancies were seen when comparing the adolescents' perceived barriers with what their parents perceived as barriers. Adolescents reported that frequent alarms and the pain of insertion were the most frequent barriers to CGM usage, whereas their parents reported that the change to the adolescent's body image was a bigger barrier. The discrepancy between the two viewpoints highlights a very common experience in the clinic. The parents as well as the diabetes team tend to seek more abstract themes as possible diabetes barriers (body image, meaning and acceptance of diabetes) while the adolescents tend to focus on more practical issues. If indeed the above conclusion is correct, there is hope for fewer complaints in this age group with improved technology. Hermanides J 1 , Nørgaard K 2 , Bruttomesso D 3 , Mathieu C 4 , Frid A 5 , Dayan CM 6 , Diem P 7 , Fermon C 8 , Wentholt IME 1 , Hoekstra JBL 1 , DeVries JH 1 1 Department of Internal Medicine, Academic Medical Centre, Amsterdam, The Netherlands, 2 Department of Endocrinology, Hvidovre University Hospital, Hvidovre, Denmark, 3 Department of Clinical and Experimental Medicine, Division of Metabolic Diseases, University of Padova, Padova, Italy, 4 Department of Endocrinology, Catholic University Leuven, Leuven, Belgium, 5 Division of Diabetes and Endocrinology, Malmö University Hospital, Malmö, Sweden, 6 Department of Medicine, University of Bristol, Bristol, UK, 7 Division of Endocrinology, Diabetes and Clinical Nutrition, University Hospital and University of Bern, Bern, Switzerland, and 8 Centre d'éducation pour le traitement de diabète et des maladies de la nutrition, Centre Hospitalier de Roubaix, Roubaix, France Diabet Med 2011; 28 : 1158–67 Aim: The aim of this study was to examine the effectiveness of sensor augmented pump therapy vs. multiple daily injection therapy in patients with poorly controlled T1D (A1c ≥ 8.2%). Methods: In total, 83 patients with T1D (40 women) currently treated with MDI, aged 18–65 years, were randomly assigned to 26 weeks of treatment with either a sensor-augmented insulin pump (SAP) (n = 44) (Paradigm® REAL-Time) or MDI (n = 39). Change in HbA1c between baseline and 26 weeks, sensor derived endpoints and patient reported outcomes were assessed. Results: The mean HbA1c at baseline changed from 8.46% (SD 0.95) to 7.23% (SD 0.65) in the SAP group and from 8.59% (SD 0.82) to 8.46% (SD 1.04) in the MDI group. Mean difference in change in HbA1c after 26 weeks was –1.21% (95% confidence interval –1.52 to –0.90, p < 0.001) in favour of the SAP group. This advantage was achieved without increasing the percentage of time spent in hypoglycaemia. The SAP group showed an improvement in the Problem Areas in Diabetes and Diabetes Treatment Satisfaction Questionnaire scores. Conclusions: SAP therapy significantly decreased HbA1c in T1D patients poorly controlled on MDI therapy. Comment: This study is smaller in size but with similar study design to the Star 3 study, except in the Star 3 trial the enrolment A1c was >7.3%. In both studies SAP therapy was compared with intensive MDI therapy. In both studies there was a significant improvement in the SAP group in comparison with the MDI group. The SAP group also showed increased satisfaction scores as measured by the Problem Areas in Diabetes and Diabetes Treatment Satisfaction Questionnaire. When comparing the quality of life scores between the two groups (measured by using the SF-36v2), there was almost no significant difference. This again demonstrates the relative insensitivity of quality of life measures to significant changes in diabetes control and diabetes related issues. Patton SR 1 , Williams LB 2 , Eder SJ 1 , Crawford MJ 3 , Dolan L 4 , Powers SW 5 1 Department of Pediatrics, University of Michigan/CS Mott Children's Hospital, Ann Arbor, MI, USA, 2 Department of Pediatrics, University of South Florida, Tampa, FL, USA, 3 Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA, 4 Department of Pediatrics, Division of Pediatric Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA, and 5 Department of Pediatrics, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA Pediatric Diabetes 2011; 12 : 18–24 Aim: The purpose of this study was to assess the feasibility of obtaining retrospective CGM data in young children with T1D. CGM provides moment-to-moment tracking of glucose concentrations and measures of intra- and inter-day variability. Methods: A total of 31 children (mean age 5.0 years) with T1D used a blinded Medtronic Minimed CGM for a mean of 66.8 h. The CGM was inserted in diabetes clinics and parents were instructed for 1 h on its usage. Results: Few difficulties were reported by families in wearing the sensor for a mean of 66 h. The authors compared participants' CGM data with SMBG data and also data from older children with T1D to show differences in glucose variability existing in this population. Increased glucose variability was associated with a history of hypoglycaemic seizures. Conclusions: CGM can be used as an acceptable research tool for obtaining glucose data in young children with T1D who frequently experience more glucose variability. Data achieved through CGM are richer and more detailed than traditional SMBG data and allow analyses of how behaviour may affect blood glucose levels. Comment: This is one of a few studies that have assessed the use of CGM in young children less than 7 years of age with T1D, and once again it demonstrates increased glycaemic variability in this age group. As the authors emphasised, the reason for this study is the growing evidence suggesting that 'glucose variability is a key factor in the risk for diabetes-related complications' (i.e. microvascular complications in adults). Another variable examined in this study was diabetes-related adherence such as number of omitted insulin dosages at meals or snacks per week, daily blood glucose monitoring frequency, and number of meals or snacks per day. These young children had a mean glucose of 191 mg/dl and only 5% of readings were less than 70 mg/dl, indicating that the parents may have intentionally kept them with higher blood glucose levels. Some recent studies indicate that parental fear of hypoglycaemia may be a barrier to optimal glycaemic control. Patton et al. (2, 3) examined this issue with a modified version of the fear of hypoglycaemia scale (the Hypoglycemia Fear Survey – Parents of Young Children, HFS-PYC). They found that mothers of young children who experienced a seizure were more worried and tended to have more hypoglycaemia-fear behaviour than mothers of young children who had never had a seizure. Mothers reported higher total HFS-PYC scores and higher scores on the behaviour subscale, and reported greater use of strategies that increase blood glucose levels than fathers. The authors also suggest that mothers of young children with T1D often assume the majority of care for their child's diabetes. Back to the current study, the authors suggest that CGM 'can be particularly useful for behavioural researchers examining associations between patients' psychosocial functioning, self-care behaviours, and their glycaemic control, which evidence suggests should be a target for future behavioural interventions'. According to the studies cited above, reducing parental fear of hypoglycaemia may be an important goal for this kind of intervention. The use of pumps with a low glucose suspend feature or predictive pump shut-off to prevent hypoglycaemia may be particularly appropriate in this age group where there is a high level of anxiety about hypoglycaemia. Patton SR 1,2 , Eder S 1,2 , Schwab J 2,3 , Sisson CM 2,3 1 Division of Child Behavioral Health, C.S. Mott Children's Hospital, Ann Arbor, MI, USA, 2 University of Michigan Medical School, Department of Pediatrics, Ann Arbor, MI, USA, and 3Division of Endocrinology, C.S. Mott Children's Hospital, Ann Arbor, MI, USA J Pediatr Health Care 2010; 24 : 365–71 Background: Injection site rotation is an important constituent of insulin regimen and is helpful in preventing lipodystrophy in T1D. This study examined the number of injection/infusion sites used by youth with T1D and their perceived obstacles to using new sites in rotation for insulin administration. Methods: A total of 201 adolescents with T1D completed a 24-item survey about site rotation practices and obstacles to site rotation during a routine diabetes appointment. Results: Fifteen per cent of adolescents reported using at least four different sites in their rotation plan, while 22% reported using only one site. A negative association was found between number of sites used and the number of perceived obstacles reported by youth on multiple daily injections. Fear of pain was the most frequent obstacle reported by adolescents. Conclusion: Adherence to an appropriate site rotation plan may be a problem for many adolescents with T1D. Regular evaluation of insulin sites and counselling regarding appropriate site rotation is needed when managing diabetes among adolescents. Fear of pain when rotating to new insulin sites may be reduced with the help of relaxation and distraction among adolescents. Comment: One of the common issues with both multiple daily injections and pump therapy is a tendency for patients to administer their insulin in one or two 'favourite' sites. When they do, insulin stimulates lipohypertrophy, and insulin injections are less painful in this lipohypertrophied site. The lipohypertrophy and eventual scar tissue formation at these favoured sites can also alter insulin pharmacodynamics which may prevent optimal insulin absorption and may eventually cause a decline in metabolic control (4, 5). Adolescents report fear from pain in rotating to new insulin sites as the most common barrier for adherence to site rotation. Only a third of youth on CSII use the recommended site rotation. Although 61% of youth on a CSII regimen recognise that site rotation will improve their diabetes control, 67% of the same group mentioned comfort with their existing routine as a barrier to adopting new sites. With the addition of CGM site rotation becomes a much bigger issue since, at any one time, two sites are occupied, and in young children the real estate of skin becomes an even bigger issue. The insulin causes lipohypertrophy which is not a problem with sensors; however, both pumps and sensors require adhesive tape. Every time tape is pulled off the skin it removes the top layer of the epidermis which is an important barrier to skin infections. If a site is used repeatedly, it does not allow time for the skin to heal and increases the risk for an infection where the sensor or infusion set needle penetrates the skin. The use of multiple adhesive tapes also increases the risk of tape allergy. Fear of pain and fear of change are the main barriers to site rotation. The authors suggest that using relaxation and distraction techniques will help children cope with their fear while they become more familiar with new injection sites. The field of relaxation and distraction has developed in recent years along with recognition of its effectiveness. Pain no longer seems a physiological phenomenon per se but a complicated experience containing both physiological and psychological factors, especially anxiety and the inability to relax. This field provides options such as meditation, relaxation and virtual techniques which will help the diabetes team expand their box of tools and improve patient adherence to treatment. Nixon R, Pickup JC Diabetes Research Group, King's College London School of Medicine, Guy's Hospital, London, UK Diabetes Technol Ther 2011; 13 : 93–8 Aim: The aim of this study was to examine the scope of fear of hypoglycaemia in patients with T1D using CSII and to test the hypothesis that poor glycaemic control during CSII is associated with fear of hypoglycaemia. Methods: The authors interviewed non-pregnant T1D patients attending an insulin pump clinic with at least 6 months' duration of CSII. In 104 subjects, fear of hypoglycaemia was evaluated by questionnaire; 75 responded. Results: The median duration of CSII was 5 years (range 1–29 years). Suboptimal glycaemic control [haemoglobin A1c (HbA1c) ≥ 8.5%] was present in 27%, and this group had more men than the good control group with HbA1c < 7.0% (43% vs. 11%). Significant fear of hypoglycaemia (score > 50%) occurred in 27% of subjects, but fear of hypoglycaemia was not related to HbA1c. Accumulated episodes and rate of severe hypoglycaemia were the only significant correlates of fear of hypoglycaemia (r = 0.48, p < 0.001). The HbA1c on CSII was correlated with the mean HbA1c for the 6 months on MDI therapy prior to starting CSII (p < 0.0001). Conclusions: Fear of hypoglycaemia is not correlated with HbA1c levels of patients using CSII therapy. Other factors (such as their previous HbA1c on MDI therapy and adherence to insulin pump procedures) are likely to be more significant. However, marked fear of hypoglycaemia exists in many CSII-treated people and may indirectly affect quality of life and psychological well-being. Giménez M, Lara M, Conget I Endocrinology and Diabetes Unit, Institute of Biomedical Investigations August Pi i Sunyer, CIBER of Diabetes and Associated Metabolic Diseases and Hospital Clínic i Universitari, Barcelona, Spain Diabetes Technol Ther 2010; 12 : 517–21 Aim: The purpose of this study was to evaluate the effect of initiation of CSII therapy on hypoglycaemia awareness and on glucose profiles in adults with T1D followed for 2 years after CSII initiation. Patients were recruited into the study with a history of repeated non-severe (NS) or severe (SH) hypoglycaemic episodes. Methods: The authors included in the study subjects who were older than 18 years with T1D duration of more than 5 years who were on multiple doses of insulin, without microvascular or macrovascular complications, and who had more than four NS events per week (in the last 8 weeks) and more than two SH events (in the last 2 years). NS/SH episodes and hypoglycaemia awareness were evaluated at baseline and at 6, 12 and 24 months after starting CSII therapy. A 72-h CGM was performed and subjects had a hypoglycaemic clamp to test for symptoms of hypoglycaemia at baseline and after 24 months of CSII. Quality of life was also evaluated after 6, 12 and 24 months. Results: A total of 20 patients were included (mean age 34.0 ± 7.5 years, 12 women, mean A1c 6.7 ± 1.1%, and mean 16.2 ± 6.6 years of diabetes' duration). At baseline, 19 of 20 patients had hypoglycaemia unawareness, which decreased substantially during the follow-up to three out of 20 at 24 months. NS episodes per week decreased from 5.40 ± 2.09 at baseline to 2.75 ± 1.74 at the end of the follow-up (p < 0.001). SH episodes fell from 1.25 ± 0.44 per subject-year to 0.05 ± 0.22 after 24 months (p < 0.001). There was no change in haemoglobin A1c. With CGM, the percentage of values within 70–180 mg/dl increased (53.2 ± 11.0% to 60.3 ± 17.1%, p = 0.13), and the percentage of values <70 mg/dl diminished (13.7 ± 9.4% to 9.1 ± 5.2%, p = 0.07), after 24 months. Mean amplitude of glycaemic excursions diminished after 24 months of CSII (136 ± 28 mg/dl to 115 ± 19 mg/dl; p < 0.02). An improvement in all the aspects of quality of life was observed. The basal alteration in symptom response to an induced hypoglycaemia improved after 24 months of initiating CSII leading to a response indistinguishable from that observed in a control group of patients with T1D without repeated NS and SH. Conclusions: Use of CSII helps in preventing hypoglycaemic episodes, improving hypoglycaemia awareness, and achieving better glycaemic profile. Comment: It is thought that fear of hypoglycaemia is a major contributor to poor glycaemic control. A cognitive-emotional model and the behavioural model have been developed to explain the effect of fear of hypoglycaemia on metabolic control. If a person with diabetes is worried and troubled about having a potential hypoglycaemic episode (perhaps even severe), he/she will develop protective behaviours oriented toward preventing a hypoglycaemic attack. These behaviours include increased food intake and/or reduced insulin doses that may eventually lead to poor glycaemic control. The Hypoglycemia Fear Survey is a measurement tool based on this model. The first study challenges this well accepted assumption. According to the results no correlation was found between HbA1c on CSII and fear of hypoglycaemia. Patients with poorer glycaemic control did not report more fear of hypoglycaemia than patients with good glycaemic control. Taking a closer look at the results may provide some possible explanations. In this study 27% of the patients did have significant fear of hypoglycaemia which was correlated with the occurrence of episodes of SH. In the second study by Giménez et al. there was a decrease in the number of hypoglycaemic episodes in a group with a history of frequent episodes of hypoglycaemia and hypoglycaemia unawareness with 2 years of CSII therapy. In this study there was a significant improvement in their diabetes quality of life, which is probably related to restoration of hypoglycaemia awareness. The study, however, did not measure fear of hypoglycaemia. In another study hypoglycaemia unawareness was reversed with 4 weeks of sensor augmented pump therapy using a high hypoglycaemic threshold of 108 mg/dl (6). These studies show that CSII therapy, particularly when combined with a continuous glucose sensor, can have a major role in decreasing hypoglycaemia unawareness and fear of hypoglycaemia. There is also a group that had never experienced a severe hypoglycaemia attack but still report fear of hypoglycaemia. Gonder-Frederick et al. (7) argue that this group may possess anxiety as a trait and not as a state. Patients that have an anxious tendency are at risk of confusing symptoms of anxiety with those of hypoglycaemia. In conclusion, CSII and the use of CGM can have a major role in restoring hypoglycaemia awareness, but this does not necessarily translate into a lower A1c, although it can have a significant impact on the patients' quality of life. The use of these technologies can also be combined with a psychological approach to reduce anxiety and fear of hypoglycaemia. Shorer M 1 , David R 2 , Schoenberg-Taz M 1 , Levavi-Lavi I 3 , Phillip M 1,2 , Meyerovitch J 1,2 1 Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel, 2 Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel, and 3 Department of Medical Psychology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel Diabetes Care 2011; 34 : 1–3 Aim: The aim of this study was to examine the role of parenting style in achieving metabolic control and treatment adherence in youth with T1D. Methods: Parents of 100 adolescents with T1D completed questionnaires on their parenting style and sense of helplessness. The patient's adherence to the treatment regimen was rated by both parents and patients. Glycaemic control was evaluated by HbA1c values. Results: Better glycaemic control was predicted by utilising an authoritative paternal parenting style and adherence in the child; a permissive maternal parenting style predicted poor adherence. A higher sense of helplessness in both parents predicted suboptimal glycaemic control and poorer adherence to treatment. A sense of helplessness in parents was a significant predictor of diabetes control after correcting for other confounders (patient age, sex and treatment method). Conclusions: An authoritative non-helpless parenting style is correlated with better diabetes control in youth. The authors conclude that paternal involvement is important in youth diabetes management and remark that these results have implications for psychological interventions. Comment: The problem of motivation in patients with diabetes is without doubt one of the most important issues in diabetes care. Since a patient's adherence to treatment still plays a central role in glucose control, being non-cooperative to treatment regimen can cause poor glucose control. Multiple studies have shown that diabetes technology may be very successful when used by well controlled patients and parents who have high motivation and receive support of specialised diabetes care centres with expertise in diabetes technology. Nimri et al. (8) reported that 'Continuous subcutaneous insulin infusion improves glycemic control in children and adolescents with type 1 diabetes, especially those with a history of moderate to poor glycemic control' but the authors also mentioned that a possible explanation of the better glycaemic improvement in children compared with the adolescent group might be related to the parental supervision of the young children and their greater motivation. It seems that there is no single solution for motivating diabetes patients. The diabetes team will have to be creative and to attack this problem from many different angles including increased parental involvement. Borusa JS 1 , Laffel L 2 1 Division of Adolescent/Young Adult Medicine, Department of Medicine, Children's Hospital Boston, Boston, MA, USA, and 2 Pediatric, Adolescent and Young Adult Section, Genetics and Epidemiology Section, Joslin Diabetes Center, Harvard Medical School, Boston, MA, USA Curr Opin Pediatr 2010; 22 : 405–11 Background: Although efficient therapies are available, there is still poor treatment adherence among teens with T1D compared with other children. The purpose of this paper was to review the obstacles that influence adherence and discuss interventions that have shown promise in improving results for this age group. Results: Adolescents face many barriers to adherence, including developmental behaviours, changes in family dynamics, and the adolescent's own perception of social stress, as well as the physiological insulin resistance brought on by pubertal physiology. Some successful treatments have been based on encouraging non-judgmental family support in the daily tasks of blood glucose monitoring and insulin regimen. Other interventions have utilised motivational interviewing and problem-solving techniques, flexibility in nutrition recommendations, and extending provider outreach and support with technology. Summary: Effective treatments build upon adolescents internal and external supports (family, technology and internal motivation) in order to make their management of diabetes simpler and provide opportunities for the adolescents to share the burden of care. Although such strategies help reduce the demands placed upon adolescents with diabetes, poor glycaemic control will probably persist for the majority of adolescents until technological breakthroughs allow for automated insulin delivery in closed-loop systems. Comment: The problem of compliance and adherence is one of the central issues that medical and rehabilitation psychology deals with. Increased adherence to diabetes management favourably impacts glycaemic control and lower haemoglobin A1c (HbA1c) levels reduce the risk for diabetes complications. It is therefore accepted that psychological treatment should focus on increasing adherence to diabetes treatment. In their discussion the authors point out that adherence is not necessarily an independent factor. Rather, 'there is a constellation of factors that impacts adherence in adolescents with type 1 diabetes'. These factors include both modifiable and unmodifiable factors. One of these factors is implementation of technologies for diabetes management (alongside diabetes-specific family conflict, increased family involvement with diabetes management and gender- and age-specific issues). Diabetes technology in general and continuous glucose monitors in particular may become an obstacle for teens rather than a useful instrument. Adolescents tend to overemphasise the demands and personal intrusions caused by the CGM use and ignore its benefits. The authors suggest that 'strategies to increase treatment adherence for teens must require minimal distraction from the teen's routine tasks of daily living'. We indeed agree and suggest that people who develop new technologies for patients with diabetes should remember that any new technology should reduce the burden imposed on the patients especially in the adolescent age group. AL declares no conflict of interest. BB received research support from Medtronic, DexCom, Abbott Diabetes Care and Unomedical; and is a member of the medical advisory board for Medtronic, Unomedical, Animas and BD. MP's institution received research grant or support from: Dexcom, Roche, Insulet, Novo Nordisk, Sanofi-Aventis, Eli-Lilly, Andromeda, Medtronic. MP holds stock in CGM3 Ltd and D-Medical and is a consultant to D-Medical, Bristol-Myers-Squibb, AstraZeneca, Physical Logic, Andromeda, Novo Nordisk, Sanofi-Aventis.