Becky McCall

September 17, 2014

VIENNA — Multidisciplinary, structured, educational interventions for the management of type 1 diabetes, particularly those addressing carbohydrate management during the transition from pediatric to adult care, improve glycemic control, an Italian study shows.

Presenting the results here at the European Association for the Study of Diabetes 2014 Meeting, lead researcher, diabetologist Andrea Da Porto, MD, from the University Hospital of Trieste, Italy, highlighted the common problems encountered when patients transfer from the pediatric to the adult clinic.

He explained that those under the age of 16 usually have little autonomy over their disease management, with their parents playing the dominant role. Consequently, the move to adult care can often be too great a burden for most young patients.

"In the absence of disease-control education, these young adults are often at a loss for how to manage their disease. I believe the best developmental stage at which to educate is in young adults rather than in children 16 years or younger."

He drew particular attention to how their educational program showed a distinct improvement in patients who learned how to count carbohydrates, with an improvement of 12.8% (P = .037), as well as an improvement in adherence to a set carbohydrate allowance per meal of 38.8% (P = .014). This translated into better glycemic control: "The combination of better carbohydrate management correlated and was associated with a reduction in HbA1c at 6 months and 12 months."

"Many young patients who move from other centers do not have enough experience in carbohydrate management," he commented.

Program Team Includes Diabetologists, Dieticians, and Nurses

In the study, glycemic-control parameters were measured as an indicator of the effectiveness of the structured educational program and included HbA1c levels and glycemic variability, as well as the frequency of hypoglycemic events. These data were obtained from an analysis of personal blood glucose meters during a period of 90 days.

At baseline, information was collected from 55 patients with an average age of 27.8 years (+10.1 years) who had undergone the transition to the Trieste center between 2010 and 2013. Dr. Da Porto explained that they have a particularly wide age range of transitioning patients at their center.

At the initial visit, sociodemographic data, diabetologic history, transition data, and baseline glycemic-control parameters were collected. In addition, the proportion of patients who correctly counted their carbohydrates was assessed, as was the number who adhered to a constant-carbohydrate diet. These clinical parameters were reassessed at 12-month follow-up.

The multidisciplinary structured education program was conducted over a period of 12 months with regular reinforcements (at least 6 times) and was implemented by a team consisting of a diabetologist, a dietician, and a diabetes nurse.

Topics addressed include carbohydrate counting and adherence to a constant-carbohydrate diet; management of insulin and carbohydrate supply; and correction of hypoglycemia. Patients received one-to-one attention with printed material as support.

Unsurprisingly, Dr. Da Porto found that the greatest increase in HbA1c occurred during the transition period, by an average of 0.39%. But after 6 months on the program, this level dropped by 0.15%, and after 12 months it dropped further to 0.72% (P = .009).

"The transition gap showed the worst rise, but then after the intervention we saw a decrease in HbA1c during follow-up."

"We found that educational intervention led to better management of carbohydrates, and this was associated with improved glycemic control, because the patients gained the necessary understanding and skills to better manage their own disease," he explained.

Furthermore, he highlighted that these results were achieved without the need to modify drug therapy. "We are not making indisputable claims, but we believe most of the effect is due to the educational intervention."

When to Educate Young Patients in Disease Management

The session also featured some discussion about the optimal time to educate young patients about management of their disease. Dr. Da Porto noted that the United Kingdom–based CASCADE study demonstrated that educational strategies in the under-16s were not sufficiently effective at one-year follow-up.

"This is because the message doesn't fully register with patients of this age. I think we need to educate our patients when they arrive at adult centers," he said.

He treats young adult patients at the age of 18 or 19 and believes that this is the correct age to begin disease-related education. "But this education needs to be reinforced during follow-up. Our study shows the importance of the continuum of education with frequent reinforcement. We need to spend more time with patients, particularly at this transitional stage, to correct their understanding of their disease."

Dr. Eva Hommel, MD, diabetologist at the Steno Diabetes Center, Gentofte, Denmark, works with adolescents with type 1 diabetes and is also involved with the transition process from the pediatric to the adult clinic.

"We aim to ensure that patients transferring from pediatric to adult care do not go longer than 2 months before being seen, usually at around age 18," she told Medscape Medical News.

"The work by Dr. Da Porto was interesting, because for the carbohydrate counts, I think it would be useful if young people could learn this in the pediatric clinic prior to transfer.

"They are introduced to it when they receive insulin-pump treatment, but they don't use it every day as far as I can see in our clinics. I think this could be a really useful tool to introduce, and this is what we are trying to do in our clinic," she noted.

Drs. Da Porto and Hommel have declared no relevant financial relationships.

European Association for the Study of Diabetes 2014 Meeting; September 17, 2014; Vienna, Austria. Abstract 18

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