In This Issue of Diabetes Care

New therapies that can delay stage 3 clinical type 1 diabetes are leading to increasing interest in general population screening for islet autoantibodies to identify individuals at risk for the disease. However, according to O’Donnell et al. (p. 2155), this interest in screening is also generating high levels of anxiety among parents about their child’s risk for developing type 1 diabetes. Consequently, they suggest that assessment and management of anxiety should be a part of the screening process to support affected families. Based on a screening population of just over 23,800 children, the authors identified 319 children aged 1–17 years with islet autoantibodies. A total of 280 children and their caregivers where enrolled in a follow-up education and monitoring program aimed at the prevention of diabetic ketoacidosis at diagnosis. Parents were then asked to complete questionnaires to assess risk perception and anxiety about their child’s risk of developing type 1 diabetes. The authors found that at the first visit, mean parental anxiety was well above the clinical cutoff of the State Anxiety Inventory assessment and remained elevated at a subsequent monitoring visit. They note that parents with a lower education level or from racial and ethnic minority backgrounds had a particularly high level of risk for elevated anxiety. Only half of parents indicated that they thought their child was at increased risk for type 1 diabetes, highlighting how challenging it is to understand information about risk. Parents of children with multiple islet autoantibodies and who had a first-degree relative with type 1 diabetes were more likely to understand that their child was at risk for the disease. “These data highlight the value of a multidisciplinary team when assessing and providing care to this unique population of children and families,” said author Holly K. O’Donnell. “Our hope is that by providing comprehensive care we can reduce stress for families while also improving engagement in screening and monitoring programs.”

Effective glycemia control at prediabetes levels is warranted to preserve brain health and prevent neurobiological issues associated with prediabetes, according to Shin et al. (p. 2267). Specifically, it seems that there is an association between glycated hemoglobin (HbA_1c) and thickness of the cerebral cortex, with the relationship being noncontinuous and emerging negatively in the early/low prediabetes range. Based on the outcome, the authors recommend improved glycemic control at this point in the development of diabetes to preserve brain health. The findings come from an analysis of just over 30,000 individuals included in the UK Biobank. Blood HbA_1c levels were determined and cortical thickness (CT) measured via MRI. The authors also used cell-specific gene expression analyses and a genome-wide association study (GWAS) to identify cellular mechanisms that might be involved. They found that the HbA_1c-CT relationship was noncontinuous, appearing to emerge negatively within the prediabetes range at 39.6 mmol/mol (5.8%). Looking at various brain regions, they found that the association was strongest in regions with higher expression of genes specific to excitatory neurons and lower expression of genes specific to astrocytes and microglia. The GWAS also revealed a significant locus that implicated mitochondrial maintenance and ATP generation. The authors describe the association between HbA_1c and CT as a potentially weak form of excitotoxicity brought on by subtle metabolic aberrations associated with having prediabetes and possibly the depletion of ATP. On that basis, they recommend enhanced glycemic control early in the development of type 2 diabetes and highlight the potential importance of the biological processes involved. They note several strengths of the study but also that it is limited to a single ancestry (British European) and that it is cross-sectional in design. “We believe our findings are relevant to healthy brain aging,” said author Zdenka Pausova. “Further studies in populations that may be more vulnerable to type 2 diabetes are warranted.”

A national estimate of diabetes prevalence among U.S. migrant farmworkers by Olson et al. (p. 2188) suggests that 13.5% have diabetes and nearly one-third face at least one barrier to care that was most often cost related. The authors also found that migrants with poor access to care had significantly lower odds of reporting known diabetes. The findings come from an analysis of the 2008–2017 National Agricultural Workers Surveys, which used face-to-face interviews of just under 17,000 U.S. farmworkers to collect demographic, employment, and health data. The authors found that migrant farmworkers tended to lack health insurance, had a low income (i.e., <$20,000 per year), had less education, and were more commonly Spanish rather than English speaking. As well as having barriers to care and higher age-adjusted prevalence of diabetes than those who had access to health care, migrants with poor access to care were significantly less likely than nonmigrants (adjusted odds ratio 0.17, 95% CI 0.06–0.54) to report a prior diagnosis of diabetes. “Migrant farmworkers often endure dangerous working conditions and socioeconomic stress that likely harms their health,” said author Rose McKeon Olson. “Many migrant farmworkers face barriers to health care, which likely contributes to underdetection of diabetes in this high-risk population.” The authors note that the estimates of diabetes prevalence are likely to be underestimates mainly because of significant rates of undiagnosed diabetes. “Due to their dynamic travel patterns and inherently seasonal work, migrant farmworkers are incredibly difficult to study,” added Olson. “Our research presents the first national estimate of diabetes among migrant farmworkers, yet it almost certainly underestimates the true burden of disease in this vulnerable population.” According to Olson, future research should include laboratory confirmation of diabetes and partnerships with local farms to implement work-based screening and education. “Improved diagnosis must be linked with access to dependable, affordable health care; cost was the most frequently cited barrier to care among migrant farmworkers,” Olson added.

Automated insulin delivery (AID) should be considered as a treatment to reduce hypoglycemia in adults with type 1 diabetes at high risk for hypoglycemia, according to Renard et al. (p. 2180). Specifically, the approach reduced time below range, and thus risk for hypoglycemia, more than twofold compared with that for control individuals. The findings come from a prospective randomized controlled trial in which individuals with type 1 diabetes and high levels of hypoglycemia were enrolled 2:1 to use an AID approach versus a control approach using continuous glucose monitoring and insulin pump therapy for 12 weeks. The primary outcome was time below range from baseline, and a series of secondary outcomes were also included. There was also an optional 12-week extension where all participants were offered AID to assess sustainability of using the approach. The authors found that AID resulted in a significant reduction in time below range of –3.7% compared with the control individuals. There was also a significant increase in time in range of 8.6% and a decrease in time above range of –5.3%. The effects of AID were sustained in the AID group in the 12-week extension and reproduced in the control group. Prior studies have shown the benefits of AID systems in type 1 diabetes, but surprisingly few studies have focused on individuals with high risk for hypoglycemia due to impaired hypoglycemia awareness. The authors note that there were several hypoglycemia events, including two severe hypoglycemia events, while participants were using AID. They note that the events should be interpreted in the light of participants having very high risks for severe hypoglycemia that were all largely explainable. “These people with type 1 diabetes and recurrent severe hypoglycemia are among the most difficult ones to manage,” said author Eric Renard. “Our study strongly suggests AID should be considered before more complex options such as pancreas or islet transplantation. Interestingly, hypoglycemia awareness tended to be restored with sustained AID use.”