Continuous Glucose Monitoring Decreases Hypoglycemia Avoidance Behaviors, but Not Worry in Parents of Youth With New Onset Type 1 Diabetes.

BACKGROUND: Existing research shows that hypoglycemia fear (HF) is common in parents of children with established type 1 diabetes (T1D). We examined parental HF in the T1D recent-onset period and evaluated whether continuous glucose monitoring (CGM) adoption relates to improved outcomes of parental HF. METHODS: In TACKLE-T1D, a prospective study of five- to nine-year olds with recent-onset T1D, parents completed the Hypoglycemia Fear Survey-Parents (HFS-P) at baseline (T1) and 6 (T2) and 12 (T3) months post-baseline. The HFS-P measures worry about hypoglycemia (HFS-Worry score) as well as hypoglycemia avoidance behaviors (HFS-Behavior score). We recorded CGM start dates for youth during the same time period through medical record review. RESULTS: Between T1 and T2, 31 youth (32.3%) initiated CGM therapy, and between T2 and T3, an additional 17 youth (17.7%) began using CGM, leaving 48 youth who never initiated CGM therapy (50%) in the recent-onset period. Parents reported moderate HFS-Worry scores at T1 (32.9 ± 11.9), which increased between T1 and T2 (37.6 ± 11.4, P < .001) and plateaued between T2 and T3 (37.7 ± 12.4, P = .89). In contrast, parental HFS-Behavior scores decreased between T1 (33.1 ± 5.8) and T2 (32.2 ± 6.0, P = .005) and plateaued between T2 and T3 (32.2 ± 6.0, P = .95). Baseline HFS-Behavior and Worry scores were associated with increased adoption of CGM between T1-T2 and T2-T3, respectively. Parents of children initiating CGM therapy between T1 and T2 showed the largest decrease in HFS-Behavior (P = .03). CONCLUSIONS: Initiating CGM therapy within the first 12 months of T1D may help reduce parents' use of hypoglycemia avoidance behaviors, but has little effect on parents' hypoglycemia worry.

Stressful life events, parental psychosocial factors, and glycemic management in school-aged children during the 1 year follow-up of new-onset type 1 diabetes.

OBJECTIVE: To monitor occurrence of stressful life events, assess correlations with family functioning and parental psychosocial measures, and examine the impact of stressful life events on diabetes management in the first year after diagnosis of type 1 diabetes (T1D) in children using a mixed methods design. METHODS: In a prospective study of 5- to 9-year-olds with recent-onset T1D (mean age 7.4 ± 1.3 years, T1D duration 4.7 ± 3.3 months), we monitored glycated hemoglobin A1c (HbA1c), income, job status, family health, and marital status at baseline and every 3 months up to 1 year. We measured coping, parental depression, and diabetes family conflict at baseline. RESULTS: Of 128 families, 53.9% (n = 69) reported 1+ stressful event, with 25.8% reporting income change (n = 33) during this period, 23.4% additional family health changes (n = 30), 22.7% job changes (n = 29), 21.9% changes in child's school (n = 28), and 3.9% changes in marital status (n = 5). Baseline active avoidance coping, parental depression, and diabetes family conflict correlated with a higher number of stressful life events (r = 0.239, P < .01; r = 0.197, P < .05; r = 0.225, P < .01, respectively). There were also cross-sectional associations between HbA1c and income decrease, school change, and job change at various time points in the study. CONCLUSIONS: Families can experience concurrent life stressors during the first year of T1D, which relate to coping, depression, and conflict. Consistent with existing literature, stressful life events relate to glycemic management. Future research should explore the individual's or parent's perception of stress and ways that diabetes centers can effectively assist families of youth with T1D and concurrent life stressors.

Suicide Risk Assessment in Youth and Young Adults With Type 1 Diabetes.

OBJECTIVE: To describe sociodemographic and clinical characteristics of youth and young adults with type 1 diabetes who endorsed suicidal ideations as part of routine depression screening and the results of their suicide risk assessments. RESEARCH DESIGN AND METHODS: The Patient Health Questionnaire-9 was used to assess depressive symptoms and suicide/death ideation in 550 youth and young adults with type 1 diabetes ages 10-24 years. Only individuals who endorsed suicidal/death ideations (n = 49) completed a standardized suicide risk assessment protocol and safety planning. RESULTS: Nine percent of individuals endorsed suicidal/death ideation and of those, 83.4% reported clinically elevated depressive symptoms; 16% made a previous suicide attempt. No youth (n = 39) or young adults (n = 11) disclosed current plans or preparations for suicide, but five who expressed suicidal ideation acknowledged the lethality of insulin for an attempt. Three previously used insulin to attempt suicide. The overwhelming majority of individuals were classified as being low risk for future suicide attempt/completion. None were hospitalized as a part of the suicide risk assessment, and no suicide completions have occurred. CONCLUSIONS: The findings of this study provide initial insight into the behaviors and cognitions of youth and young adults with type 1 diabetes who experience suicidal and death ideations. Comprehensive suicide risk assessment and safety planning are feasible during routine type 1 diabetes clinic appointments.

Prevalence, characteristics, and diabetes management in children with comorbid autism spectrum disorder and type 1 diabetes.

OBJECTIVE: To determine autism spectrum disorder (ASD) prevalence within our pediatric type 1 diabetes (T1D) clinic population and determine clinical characteristics and technology used by individuals with both ASD and T1D compared to matched controls with T1D alone and compared to our overall pediatric T1D clinic. METHODS: Medical chart review showed 30 individuals with both ASD and type 1 diabetes (ASD + T1D). Controls (n = 90) were matched for age, sex, race/ethnicity, and T1D duration. ASD + T1D was compared to both matched controls and the pediatric T1D clinical population. RESULTS: ASD prevalence in the pediatric T1D population was 1.16% (CI 0.96-1.26). Compared to the T1D clinic, ASD + T1D had more males (93% vs 52%; P < 0.0001), lower hemoglobin A1c (HbA1c) (8.2% vs 8.9%; 66 vs 74 mmol/mol; P = 0.006), and lower insulin pump (CSII) use (37% vs 56%; P < 0.0001). No differences were found between ASD + T1D and matched controls in HbA1c or blood glucose checks per day. The ASD + T1D group was less likely to use CSII than matched controls (37% vs 61%; P = 0.03). HbA1c did not change after CSII initiation in ASD + T1D, but increased for matched controls. CONCLUSIONS: Prevalence of ASD in the pediatric T1D population is comparable to the general population in Colorado. Individuals with ASD may experience barriers limiting CSII use, but achieve equivalent glycemic control compared to those without ASD. CSII may be more effective in maintaining lower HbA1c over time in those with ASD than in those without ASD.

Parental depression and diabetes-specific distress after the onset of type 1 diabetes in children.

OBJECTIVE: To examine trajectories of two types of type 1 diabetes (T1D) specific distress (i.e., daily T1D management and worries about the future and long-term complications) and the moderating role of parental depression in parents of children newly diagnosed with T1D. METHOD: A total of 126 families of 5- to 9-year-olds with new-onset T1D enrolled in the study. One-hundred twenty-five families completed study measures at baseline, 102 at 6-month follow-up, and 89 at 12-month follow-up. Parents completed measures of depression and T1D-specific distress concerning daily T1D management and worries about the future and long-term complications at baseline and at 6- and 12-month follow-ups. We used multilevel modeling to examine 12-month trajectories of daily and long-term T1D-specific distress and to examine if parental depression modified these trajectories. RESULTS: Results showed a significant reduction in daily T1D-specific distress from baseline to 6-month follow-up and maintenance of daily T1D-specific distress from 6- to 12-month follow-up. The significant interaction of baseline parental depression and time indicated that parents with depressive symptoms had a smaller reduction in daily T1D-specific distress from baseline to 6-month follow-up compared to parents without depressive symptoms. Findings for long-term T1D-specific distress indicated that parents with depressive symptoms reported higher distress across all assessment points, with peak long-term T1D-specific distress for parents with depressive symptoms occurring at 6-month follow-up. CONCLUSION: Many parents experienced significant T1D-specific distress for a period of time following their child's initial diagnosis and this distress appears to be exacerbated by parental depressive symptoms. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Body mass index and brain structure in healthy children and adolescents.

Obesity is associated with cognitive dysfunction in children and adolescents, although the mechanisms underlying these deficits remain unclear. This study examined the associations between body mass index (BMI) and regional gray matter volume and white matter integrity in 120 healthy children and adolescents (6-18 years of age) who underwent magnetic resonance and diffusion tensor imaging. Bonferroni-corrected partial correlation analyses controlling for demographic and clinical characteristics revealed significant inverse associations between demographically standardized BMI values and gray matter volume of frontal (r = -0.31) and limbic (r = -0.35) brain regions. No such pattern emerged for fractional anisotropy of white matter tracts. Subsequent hierarchical regression analyses indicated that the relationship between standardized BMI and structural gray and white matter brain indices did not vary with age. These findings suggest that obesity in children and adolescents is associated with decreased volume of frontal and limbic cerebral gray matter regions. Further research is much needed to better elucidate possible brain-based mechanisms for cognitive dysfunction associated with obesity.

Body mass index and neurocognitive functioning across the adult lifespan.

OBJECTIVE: Cognitive dysfunction and structural brain abnormalities have been observed in obese versus lean individuals, but with variability across age and weight groups. The current study was designed to clarify the cognitive profile of obesity by examining performance across multiple cognitive domains in adults with wide-ranging age and weight status. METHOD: Participants (N = 732; 61% women; ages 18-88; BMI range 19-75) underwent assessment of cognitive functioning and relevant medical/demographic covariates. Neuropsychological tests were grouped by cognitive domain (via confirmatory factor analysis), and standardized scores were averaged into composite variables. RESULTS: Hierarchical linear regression analyses revealed main effects for BMI on motor (ΔR2 = .02, ß = -.15) and attention/processing speed (ΔR2 = .01, ß = -.07), whereas a significant interaction between BMI and age was observed (ΔR2 = .01, ß = -.08) for predicting executive functioning (p < .05). BMI was not independently associated with memory or language functioning and no interaction effects were observed for these variables. Although BMI was not independently related to executive dysfunction, a significant age × BMI interaction suggests that obesity-related executive deficits may increase with age. CONCLUSIONS: Overall, these findings may support an independent association between obesity and a frontal-subcortical pathology, though prospective studies are needed to further clarify this possibility.

Cognitive reserve preserves cognitive function in obese individuals.

Obesity is an established risk factor for cognitive impairment. Theories of cognitive reserve suggest that premorbid factors, such as intellectual ability, may attenuate the expression of cognitive impairment due to age or disease. The current study examined whether cognitive reserve, defined as estimated premorbid intellectual ability, moderates the relationship between obesity and cognitive function in obese adults. Participants without major medical or psychological conditions completed a computerized battery of neuropsychological tests. Hierarchical regression models found a significant interaction between BMI and cognitive reserve for attention/executive function and memory, suggesting that cognitive reserve attenuates the expression of obesity-related cognitive impairment.

Can bariatric surgery reduce risk of Alzheimer's disease?

Recent studies demonstrate that obesity is independently associated with poor neurocognitive outcomes, including cognitive impairment, increased risk for dementia, and regional alterations in brain structure. Bariatric surgery is an effective treatment for obesity and initial findings suggest that it may result in cognitive improvements. The current paper reviews and integrates recent research in this area, with a focus on potential mediators and moderators of neuropsychological outcome in bariatric surgery patients, including anesthetic and nutritional complications, and proposes novel avenues for continued study in this area.

Obesity is associated with reduced white matter integrity in otherwise healthy adults.

Existing work demonstrates that obesity is independently associated with cognitive dysfunction and macrostructural brain changes; however, little is known about the association between obesity and white matter (WM) integrity. We explore this relationship in a large cohort of otherwise healthy subjects. The present study classified 103 adult participants from the Brain Resource International Database between 21 and 86 years of age without history of neurological, medical, or psychiatric illness according to BMI (normal weight, overweight, obese) and subjected them to diffusion tensor imaging (DTI). Resulting fractional anisotropy (FA) indexes for the corpus callosum and fornix were examined in relation to BMI and age in a multiple regression framework. Results indicated that increasing BMI was independently associated with lower FA in the genu, splenium, and fornix, and a BMI × age interaction emerged for FA in the splenium and body of the corpus callosum. When categorized, obese persons demonstrated lower FA than normal and overweight persons for all WM indexes, but no FA differences emerged between overweight and normal persons. Results indicate both a direct association between obesity and reduced WM tract integrity and an interaction between obesity and aging processes on certain WM tracts in otherwise healthy adults. While such findings suggest a possible role for adiposity in WM dysfunction and associated cognitive deficits, prospective studies are needed to clarify the nature of these relationships and elucidate underlying mechanisms.

Improvements in cognitive function following cardiac rehabilitation for older adults with cardiovascular disease.

Cognitive impairment is common in persons with cardiovascular disease (CVD). Cardiac rehabilitation (CR) improves many aspects of CVD linked to cognitive impairment. The current study explored whether CR may improve cognitive function. Potential mechanisms for cognitive changes were also examined through exploratory analyses, including changes in cardiovascular fitness and cerebral blood flow. Fifty-one older adults with CVD underwent neuropsychological assessment at baseline and discharge from a 12-week CR program. Cardiovascular fitness (i.e., metabolic equivalents [METs]) was estimated from a symptom-limited volitional stress test. Transcranial doppler quantified mean cerebral blood flow velocity and pulsatility indexes for the middle cerebral artery and anterior cerebral artery (ACA). Repeated measures ANOVA showed improvements in global cognition, attention-executive-psychomotor function, and memory. Exploratory analyses revealed improvement in METs and changes in ACA flow velocity, but only improvement in METs was related to improved verbal recall. CVD patients exhibited improvements in multiple cognitive domains following a 12-week CR program, suggesting that cognitive impairment is modifiable in this population. Although other studies are needed to elucidate underlying mechanisms, exploratory analyses suggest that cognitive improvements may be better explained by physiological processes other than improved cardiovascular fitness and cerebral blood flow.

Reduced executive functioning is associated with poorer outcome in cardiac rehabilitation.

Patients with cardiovascular disease and cognitive impairment show reduced adherence to treatment. No study has examined whether cognitive impairment may also predict reduced benefit from cardiac rehabilitation (CR). It appears that cognitively impaired patients may exhibit poorer adherence to CR and limited gains in cardiovascular fitness and/or quality of life (QOL). Forty-four older adults who enrolled in a CR program and completed measures at enrollment and discharge were included. Cognitive functioning was assessed using the Trail Making Test B. Estimated metabolic equivalents (METs) were derived from a treadmill stress test to provide a measure of cardiovascular fitness. QOL was measured with the Short Form-36 (SF-36) physical and mental component scales (PCS and MCS, respectively). Repeated measures analysis of variance showed improvements in METs [METs; F(1,36)=77.6, P<.001] and physical [SF-36 PCS; F(1,36)=14.14, P=.001)] and mental QOL [SF-36 MCS; F(1,36)=11.55, P=.002)]. Partial correlations indicated that poorer Trail Making Test B performance was associated with lower METs at discharge (r=-0.30, P<.05), but not PCS or MCS. Mini-Mental State Examination scores were not related to outcome variables. Current findings suggest that patients with poorer executive functioning derive reduced benefit from CR. CR programs may consider screening patients at baseline for low cognitive functioning to help identify those patients at greatest risk for poor outcome.

Longitudinal cognitive performance in older adults with cardiovascular disease: evidence for improvement in heart failure.

BACKGROUND: Cardiovascular disease (CVD) and particularly heart failure (HF) have been associated with cognitive impairment in cross-sectional studies, but it is unclear how cognitive impairment progresses over time in older adults with these conditions. OBJECTIVE: The aim of this study was to prospectively examine cognitive function in patients with HF versus other forms of CVD. METHOD: Seventy-five older adults (aged 53-84 years) with CVD underwent Doppler echocardiogram to evaluate cardiac status and 2 administrations of the Dementia Rating Scale (DRS), a test of global cognitive functioning, 12 months apart. RESULTS: Although DRS performance did not statistically differ between groups at either administration, a significant between-group difference in the rate of cognitive change emerged (lambda = 0.87; F = 10.50; P = .002; omega 2 = 0.11). Follow-up analyses revealed that patients with HF improved significantly on global DRS performance, whereas patients with other forms of CVD remained stable. More specifically, patients with HF showed improvement on subscales of attention, initiation/perseveration, and conceptualization. Exploratory analyses indicated that higher diastolic blood pressure at baseline was associated with improved DRS performance in patients with HF (r = 0.38; P = .02). CONCLUSIONS: Patients with HF exhibited modest cognitive improvements during 12 months, particularly in attention and executive functioning. Higher diastolic blood pressure at baseline was associated with improvement. These results suggest that cognitive impairment in patients with HF may be modifiable and that improved blood pressure control may be an important contributor to improved function. Further prospective studies are needed to replicate results and determine underlying mechanisms.

Serum leptin levels are associated with cognitive function in older adults.

Recent work suggests that leptin, a circulating adipokinine hormone, might contribute to age-related cognitive decline. The present study investigated the relationship between serum leptin levels and cognitive function in older adults. Thirty-five older adults (73.69+/-6.62 years of age) without significant neurologic or psychiatric history completed a fasting blood draw and a brief neuropsychological test battery. Partial correlations adjusting for demographic and medical conditions showed that higher leptin levels were associated with poorer performance on Trail Making Test B (r = .46, p = .01). These findings indicate that serum leptin levels are negatively associated with speeded executive function in older adults without significant neurological or psychiatric conditions. The mechanisms for this relationship are unknown and require further examination. Such studies may provide key insight into the mechanisms of age-related cognitive decline and identify possible interventions.