Diabetes Spectrum最新文献

Endogenous hypercortisolism (Cushing syndrome) is a multisystemic disease characterized by a wide range of clinical signs and symptoms. Its heterogeneous presentation can cause significant diagnostic delays, and prolonged exposure to excess cortisol activity can contribute to cardiometabolic abnormalities such as diabetes. When diabetes remains unresponsive or only partially responsive to standard-of-care treatment, clinicians should consider hypercortisolism as a potential underlying driver. Despite the risks associated with hypercortisolism, guidance on identifying and managing it in patients with diabetes remains limited. This article presents a case series of 10 patients from a single practice who were screened for hypercortisolism because of difficult-to-manage diabetes and additional comorbidities. All patients were treated for hypercortisolism with mifepristone, resulting in significant clinical improvements including weight loss, improved glycemic control, and reduced medication needs. This real-world case series highlights the importance of recognizing hypercortisolism as a differential diagnosis and a potential contributing factor to difficult-to-manage diabetes despite standard-of-care therapies. Addressing hypercortisolism with mifepristone can result in substantial clinical benefits.

Type 1 diabetes is a risk factor for developing mental health disorders, particularly disordered eating. Female adolescents are vulnerable to abnormal eating behaviors when transitioning from childhood to adult diabetes management. The challenge of achieving glycemic stability while navigating developmental changes during adolescence can lead females to unhealthy eating patterns as a coping mechanism. Disordered eating behavior is a term that encompasses a variety of patterns that do not meet the criteria for a formal eating disorder diagnosis. Such behaviors include dietary restriction, binge eating, and purging methods, including self-induced vomiting, excessive exercise, and medication misuse. The intentional omission of insulin is a purging method specific to diabetes, and especially type 1 diabetes. Without insulin, the body is unable to take up glucose from the bloodstream, resulting in hyperglycemia. A prolonged state of hyperglycemia can lead to serious complications, including diabetic ketoacidosis. A persistently elevated A1C is one of the few objective findings of disordered eating in patients with type 1 diabetes. Disordered eating instruments, including the SCOFF and Diabetes Eating Problem Survey-Revised questionnaires, have been adjusted to inquire about insulin misuse. Positive screening results and clinical findings of sustained hyperglycemia are pathognomonic of disordered eating behavior. Treatment of the concurrent conditions includes cognitive behavioral therapy with a multidisciplinary approach to regain glycemic stability. Health care providers must maintain a high index of suspicion for signs of psychosocial distress in female adolescents with type 1 diabetes to ensure that appropriate interventions are made before long-term complications arise.

Objective: Screening for type 1 diabetes provides an opportunity to identify those with presymptomatic, early-stage disease, enabling increased monitoring to prevent diabetic ketoacidosis and facilitating access to emerging therapies. Given potential benefits, discussions about population-wide type 1 diabetes screening are ongoing. Routine primary care visits could offer a scalable approach to such screening. We used mixed methods to explore multilevel barriers to and facilitators of type 1 diabetes autoantibody screening at well-child visits and, more broadly, the acceptability, appropriateness, and feasibility of such a screening approach.

Research design and methods: Semi-structured interviews were completed with parents, clinicians, and health insurers. Transcripts were double coded using an iteratively adapted a priori codebook. A survey leveraging the validated Acceptability of Implementation, Intervention Appropriateness, and Feasibility of Intervention Measures instruments was deployed to assess pediatric primary care clinician perspectives.

Results: A total of 26 parents, 10 clinicians (endocrinologists and pediatricians), and two health insurers participated in interviews, and 15 pediatricians participated in the survey. Most parents interviewed and clinicians surveyed found type 1 diabetes screening acceptable and appropriate. Parents noted lack of education, need for a blood draw, costs, difficulty scheduling, and fear of results as barriers. Clinicians reported barriers including parental views on blood draws and clinician time. Insurers described lack of insurance coverage as a barrier. Facilitators across constituents included education, reduced costs, convenient screening, guidelines supporting screening, and institutional support.

Conclusion: If population screening for type 1 diabetes is pursued, models that integrate primary care will be needed. Screening for type 1 diabetes through primary care well-child visits could enable high adoption if implementation strategies adequately address described barriers and promote facilitators.

Pregnant people with type 1 diabetes often experience considerable emotional distress when striving for tight glucose management, managing the changes in insulin sensitivity over the three trimesters, adjusting to the real risks of hypoglycemia, and dealing with a myriad of frightening feelings and pregnancy-related experiences. Thus, pregnancy-related emotional distress during the perinatal period can have profound implications for maternal and child health and well-being over time. This article provides a comprehensive description of the subjective experience of pregnancy-related emotional distress reported by many women with type 1 diabetes, reviews options for its practical assessment in clinical care, and outlines strategies for intervention.

Breastfeeding presents distinct physiological and practical challenges in individuals with type 1 or type 2 diabetes. This review examines the barriers to successful lactation in this population, evaluates evidence-based interventions to address these obstacles, provides clinical recommendations regarding medication and nutritional management, and delineates the impact of diabetes on lactation physiology.

Current recommendations encourage strict intrapartum glycemic control for individuals with diabetes in pregnancy to optimize maternal and neonatal outcomes. However, established evidence is limited in providing a strong association between strict maternal blood glucose control and neonatal outcomes.

Nutrition is a key component in the management of pregnancy. If diabetes is also involved, the maternal physiological and hormonal changes can have a profound effect on glycemic levels. Eating habits, which include what and how foods are consumed, and even culture are other contributing factors that influence maternal and fetal outcomes. Most nutrition recommendations can be applied to all pregnancies; however, adjustments may be necessary if diabetes predated the pregnancy. This article provides an update, addressing both what has and has not changed in recent years in the nutrition management of pregnancy and preexisting diabetes.

Automated insulin delivery (AID) systems have revolutionized modern diabetes care outside of pregnancy, but none of the AID systems currently available in the U.S. are approved for use during pregnancy, none have glucose targets low enough to achieve the stricter fasting glucose targets recommended during pregnancy, and none have algorithms that were designed to respond to the amplified oscillations in glycemia that occur in pregnancy or the progressive changes in insulin resistance observed over the course of gestation. Despite these limitations, many women elect to continue using AID off label during pregnancy based on consideration of individual clinical factors and preferences. This article presents some commonly encountered challenges to off-label AID use and CGM interpretation during pregnancy, along with suggested best-practice workarounds to optimize the care of pregnant individuals with diabetes using AID.