Apps, Intense Programs Help Teens With Type 1 Manage Better

Alicia Ault

June 16, 2016

NEW ORLEANS — Giving teens hands-on, high-intensity interventions — even for a short period — to help them self-manage type 1 diabetes keeps glycemic levels in check, prevents depression, and reduces days in the hospital for diabetic ketoacidosis, even for the most vulnerable, according to several small studies presented here.

The research was all presented as part of a session addressing innovative ways to self-manage at the American Diabetes Association (ADA) 2016 Scientific Sessions on June 12.

Attendees heard about an app, a specially developed program to help with depression and stress, and a novel intervention to try to prevent diabetic ketoacidosis episodes among vulnerable young people with type 1 diabetes.

There's an App for That

One of the tools discussed was the "MyDay" app, which was developed by researchers at the Vanderbilt University School of Medicine and School of Nursing, Nashville, Tennessee.

"We know that many adolescents with type 1 struggle with appropriate self-care tasks," said Sarah E Vaala, PhD, research associate, Vanderbilt University School of Nursing.

All sorts of barriers can interfere with care, among them having physical or emotional issues, being in a rush, being in a crowd, and feeling under stress. Teens aren't good at recognizing these barriers or systematically noting them and understanding how they might lead to interference with their self-care, explained Dr Vaala.

"What's really needed to help teens identify these barriers is a tool to track and display these patterns and map that onto their behavior," she said. A tool for doing that "is literally right in teens' hands" — the smartphone — which is why they were inspired to build the MyDay app, she noted.

Three times a day (at meals) and at bedtime, the app prompts users to enter data, including their mood, stress level, where they are, and who they were with, if anyone. It uses a Bluetooth-enabled glucometer to upload blood glucose data.

The results are displayed in graphical "trackers" — pie charts and bar graphs that show, for instance, the daily high HbA1c level, who they were with most often when they checked their levels, or how often they missed a check.

The Vanderbilt researchers recently completed a 6-month feasibility test with 30 teens with type 1 diabetes who used the app for a month. The mean age of participants was 15, 90% were non-Hispanic white, and almost 75% came from homes with income of more than $50,000 a year. The mean duration of disease was 6 years, and 73% (22 patients) were using an insulin pump.

After 2 weeks of app use, the teens were interviewed by phone and asked to see whether they could identify particular patterns, based on the trackers. The staff identified an average of almost 11 patterns, while the teens identified eight. For instance, the app might show that glucose checks are frequently missed at lunch. The interviewer would then guide the teen to try to determine why that happened and then set a goal to address the behavior.

The teens were able to give a reason for a behavior pattern for 68% of the patterns identified. The researchers found that, in general, combining psychosocial assessment with glucose monitoring "is facilitating critical steps in adolescents' problem solving," said Dr Vaala. It helped them recognize patterns, figure out barriers, think through the causes, and develop concrete goals for self-improvement.

The study had some limitations — for instance, the researchers did not track teens' efforts to meet those goals. But overall, she said, "2 weeks of app use is sufficient for eliminating a lot of those patterns."

Danielle M Hessler, MD, assistant professor of family community medicine, at the University of California, San Francisco School of Medicine, who chaired the session on self-management, said the app might be useful "across the lifespan," not just in the teens.

"I was especially impressed by the suggestion that a lot of the benefits could be obtained with an intensive 2 weeks," Dr Hessler told Medscape Medical News.

Self-monitoring is difficult to sustain over the long term, which makes an app that provides immediate feedback for goal setting an attractive option, she added. "I can see how that has immediate uses for the patient rather than indefinite tracking."

STePS Program Prevents Depression

Another program described in the session helped teens with type 1 diabetes with problem solving and coping as a way to prevent depression. Depression has been extensively researched in type 1, but few prevention programs have focused on youths with the disease, said Jill Weissberg-Benchell, PhD, associate professor of psychiatry and behavioral sciences at Northwestern University Feinberg School of Medicine, Chicago.

Dr Weissberg-Benchell wanted to try the Penn Resilience Program (PRP), developed by the University of Pennsylvania, on type 1 teens. That program promotes resilience by building a sense of hopefulness and teaching an optimistic explanatory style, coping skills, and positive problem solving. The program is delivered in a group setting.

In a study funded by the National Institutes of Health, they recruited participants from endocrinology practices, school nurses, diabetes education groups, and local American Diabetes Association and Juvenile Diabetes Research Foundation offices. Patients were recruited from the Chicago and San Francisco metropolitan areas.

The study randomized 133 high school students with type 1 diabetes to the PRP program and 131 to basic education. The participants in each group were 60% women, and about two-thirds were white, 12% were African American, 10% Hispanic, and 2% Asian American. Eighty percent came from two-parent homes. The mean duration of disease was about 7 years, and about 70% of the teens used a pump.

The teens "were remarkably resilient at baseline," with average levels of diabetes-specific emotional distress, said Dr Weissberg-Benchell. They self-reported a high level of adherence, but glucometer download data showed they checked blood glucose less than four times a day. HbA1c levels were typical for the group, with a median of 9.1%.

The education and PRP groups met twice a month on Sundays for a total of nine sessions. The education control group received an adolescent-focused program through certified diabetes educator nurses or others who worked in clinics with teens. The PRP group was taught the ABC model of resilience (Adversity, Beliefs, Consequences), how to put things in perspective, relaxation techniques, assertiveness training, and how to use resilience in real time. Teens were given homework in between sessions and received email and phone reminders to complete the work.

Eighty-eight percent are still participating in the program. Nine teens dropped out, and 20 stopped coming to sessions but kept on filling out questionnaires.

The researchers analyzed data from baseline, postintervention (4 months), and follow-up (8, 12, and 16 months).

They found no difference in the two groups — but neither got worse, which suggests a global prevention effect, said Dr Weissberg-Benchell.

And in teens who participated in the PRP arm who had low scores at baseline, PRP improved adherence (P = .007), diabetes distress (P = .042), and social problem solving (P = .02). There was no change in HbA1c, but there was a trend toward improvement (= .09).

"None of the kids who participated became depressed," said Dr Weissberg-Benchell, adding, "That's pretty remarkable after a year in high school — they should become much more depressed over time and they do not."

Dr Hessler, the session chair, agreed that the program seemed to be a success. After a year in high school, "we would have expected a greater increase in depressive symptoms and diagnosis of depression than was seen in this study," she told Medscape.

It would be interesting to see, however, whether the teens who participated were a low-risk group at baseline. More work needs to be done to identify depression predictors, added Dr Hessler.

Preventing DKA Hospitalizations in Most Vulnerable

A third study in the session looked at how to prevent hospitalizations for diabetic ketoacidosis in underserved youths with type 1 diabetes.

DKA is a dangerous, costly, and disruptive event, leading to 160,000 admissions to private hospitals annually at a cost of $1 billion. Sixty-five percent of such admissions are in children under age 19, said Michael A Harris, PhD, director of psychology in the Child Development and Rehabilitation Center at Oregon Health Sciences University, Portland.

Dr Harris and colleague Kim Spiro developed a program — Novel Interventions in Children's Healthcare (NICH) — to target the most socially and medically vulnerable type 1 teens — those who are minority, underserved, non-English-speaking, low-income, or cognitively impaired or have mental-health issues, for instance.

The idea behind NICH is that social ecology drives behavior and that to change behavior, it's necessary to have full access to people's lives, explained Dr Harris.

NICH participants are offered help with every aspect of life: from transportation, to medical supplies, to 24-hour access to clinicians, to help with child-protective services and the juvenile-justice system. "If they don't have a phone, we push phones out to them," said Dr Harris, adding that the program had purchased smartphones, phone plans, and iPads for NICH teens and families.

The NICH team makes multiple home visits each week and will make school visits as necessary. The program has been tested with 45 teens, with a mean age of 15 and a mean disease duration of 6 years. Of them, 86% were white; half were girls, half boys; 35% came from a single-parent home; and 58% had current or previous involvement with child-protective services. The teens live a mean of 88 miles from the diabetes center.

Seventy percent reported little or no support from family or friends.

In the year before NICH, the participants had a mean HbA1c of 11.8%; in the year during the program, it declined to 10.8%. The days in the hospital declined from almost 5 to 2.5, and annual costs decreased from about $12,000 per teen to just under $8000, and is trending toward just under $5000, said Dr Harris.

He acknowledged that the program's main drawback is its high cost and that the savings potential is not as great unless patients have had multiple diabetes-related hospitalizations or emergency-room visits.

Dr Harris has also found that only seven in 10 participants respond favorably to NICH. Even so, he has contracts with Oregon's Medicaid, Kaiser Permanente, and a variety of third-party payers to deliver the program to their high-cost type 1 teens, he said. The program is also getting a test run at Stanford University and will soon be piloted at Texas Children's Hospital in Houston, said Dr Harris.

For high-utilizing, high-cost patients, NICH does make sense, said Dr Hessler. "That's where we can see a good business case for this, or maybe even a saving," she told Medscape Medical News.

Dr Valla, Dr Hessler, and Dr Harris disclosed no relevant financial relationships. Dr Weisberg-Benchell is an author and on the speaker's bureau for Roche Diagnostics.

American Diabetes Association (ADA) 2016 Scientific Sessions; June 12, 2016; New Orleans, Louisiana. Abstracts 283-OR, 286-OR, and 288-OR


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