COVID-19 impacts and inequities among underserved communities with diabetes.

Background: People with diabetes have higher COVID-19 morbidity and mortality. These risks are amplified for underserved communities including racial/ethnic minorities and people with lower socioeconomic status. However, limited research has examined COVID-19 outcomes specifically affecting underserved communities with diabetes. Methods: From November 2021 to July 2022, adults with insulin-requiring diabetes at federally qualified health centers in Florida and California (n = 450) completed surveys examining COVID-19 outcomes and demographics. Surveys assessed COVID-19 severity, vaccination uptake, mask-wearing habits, income changes, and healthcare access changes. Surveys also included the full Coronavirus Anxiety Scale (CAS-19). Descriptive statistics were computed for all outcomes. Between-group comparisons for state and race/ethnicity were evaluated via Chi-Squared, Fisher's Exact, Cochran-Mantel-Haenszel, One-Way ANOVA, and t-tests. Logistic regression determined factors associated with COVID-19 vaccination uptake. Data were self-reported and analyzed cross-sectionally. Results: Overall, 29.7 % reported contracting COVID-19; of those, 45.3 % sought care or were hospitalized. Most (81.3 %) received ≥ 1 vaccine. Hispanics had the highest vaccination rate (91.1 %); Non-Hispanic Blacks (NHBs) had the lowest (73.9 %; p =.0281). Hispanics had 4.63x greater vaccination odds than Non-Hispanic Whites ([NHWs]; 95 % CI = [1.81, 11.89]). NHWs least often wore masks (18.8 %; p <.001). Participants reported pandemic-related healthcare changes (62 %) and higher costs of diabetes medications (41 %). Income loss was more frequent in Florida (76 %; p <.001). NHBs most frequently reported "severe" income loss (26.4 %; p =.0124). Loss of health insurance was more common among NHBs (13.3 %; p =.0416) and in Florida (9.7 %; p =.039). COVID-19 anxiety was highest among NHBs and Hispanics (IQR = [0.0, 3.0]; p =.0232) and in Florida (IQR = [0.0, 2.0]; p =.0435). Conclusions: Underserved communities with diabetes had high COVID-19 vaccine uptake but experienced significant COVID-19-related physical, psychosocial, and financial impacts. NHBs and those in Florida had worse outcomes than other racial/ethnic groups and those in California. Further research, interventions, and policy changes are needed to promote health equity for this population.

Multisite Quality Improvement Program Within the Project ECHO Diabetes Remote Network.

BACKGROUND: The telementoring Project ECHO (Extension for Community Healthcare Outcomes) model has been shown to improve disease management in diabetes in many underserved communities. The authors aim to evaluate if ECHO could also be an effective tool for quality improvement (QI) of diabetes care in these communities. METHODS: Thirteen clinics in underserved communities in California and Florida participating in Project ECHO Diabetes were recruited for a 12-month QI program. The program provided weekly tele-education sessions, including a didactic presentation and case-based discussion. In addition, clinics chose their own set of quality measures to improve and met remotely to discuss their efforts, successes, and setbacks every quarter with mentorship from QI experts. RESULTS: Of the 31 QI initiatives attempted by different clinics, all had either made improvements (25 initiatives, 80.6%) or were in the process of making improvements (6 initiatives, 19.4%) in structural, process, and outcome measures. Examples of these measures include whether clinics have protocols to identify high-risk patients (structure), numbers of continuous glucose monitor prescriptions submitted by the clinics (process), and percentage of patients with diabetes whose most recent HbA1c are > 9% (outcome). For one measure, 40.0% of the clinics had achieved a higher percentage of cumulative HbA1c measurement in the third quarter of the year, compared to the fourth quarter in the previous year. The cost of QI implementation varied widely due to different number of personnel involved across sites. CONCLUSION: A QI program delivered via Project ECHO Diabetes can facilitate quality improvements in underserved communities.

Sociodemographic factors associated with major depressive episodes and suicidal ideation among emerging adults with diabetes in the U.S.

Background: Research focused on disparities related to mental health comorbidities, especially among emerging adults with diabetes, is limited. Identifying associated factors of disparities could inform policy decisions to make diabetes-related interdisciplinary care more accessible for vulnerable groups. Method: Using data from the National Survey on Drug Use and Health (2015-2019), we examined disparities in presence of major depressive episode (MDE) and suicidal ideation among emerging adults with diabetes. Survey design-adjusted bivariate and multivariable logistic regression models were used for statistical analyses. Results: The study included 1,125 emerging adults (18-25 years old), with a history of type 1 diabetes (T1D) or type 2 diabetes (T2D). After controlling for sociodemographic and health-related characteristics, we found lower odds of having past-year major MDE for non-Hispanic Black (AOR, 0.42, p=0.032) compared to their non-Hispanic White counterparts. Females were 3.02 times more likely to have past-year MDE than males (AOR, 3.02, p=0.004). The odds of having past-year MDE were 1.96 times higher among individuals who identified as LGB (lesbian, gay, bisexual) (AOR, 1.96, P=0.038). There were no statistically significant disparities in suicidal ideation related to race/ethnicity, sex, education, and family income. However, individuals who identified as LGB had significantly higher likelihood of suicidal ideation than their heterosexual counterparts (AOR, 2.47, P=0.004). Conclusion: Significant disparities related to MDE and suicidal ideation exist based on race/ethnicity, gender, and sexual orientation. Integration of a mental health professional into the multidisciplinary diabetes care team is critical for effective management of comorbid mental health conditions in younger patients with diabetes.

The Promising Success of Project Extension for Community Healthcare Outcomes (ECHO) Diabetes: Case Series.

BACKGROUND: In the United States, there are over 37 million people with diabetes but only 8000 endocrinologists. Therefore, many people with diabetes receive care exclusively from primary care providers (PCPs). To democratize knowledge regarding insulin-requiring diabetes through tele-education, Stanford University and the University of Florida developed Project Extension for Community Healthcare Outcomes (ECHO) Diabetes. OBJECTIVE: ECHO Diabetes uses a Hub and Spoke model connecting specialists (the "Hub") with PCPs (the "Spokes"). One-hour, weekly sessions include Hub diabetes didactic presentations and Spoke deidentified case presentations. Lessons learned during these sessions target provider knowledge and confidence surrounding diabetes management and patient care. METHODS: Spokes were asked to provide short descriptions of people with diabetes whose diabetes management improved directly or indirectly from their providers' participation or their involvement with a Diabetes Support Coach (DSC). We provide a case series to describe individuals and outcomes. Because this study was not a randomized controlled trial and was a prospective observation of patients with the intervention delivered to providers, the trial is not registered in a public trials registry. RESULTS: A case series of 11 people with diabetes was compiled from 10 PCPs and 1 DSC from California and Florida between 2021 and 2022. The principal impact of ECHO Diabetes is the education amplified from PCPs and DSCs to people with diabetes. In all cases, people with diabetes reported increased engagement and improved diabetes management. Several cases reflected increased access to diabetes technology, improvement in glycemic outcomes, and positive trends in mental health measures. CONCLUSIONS: This case series elucidates the potential value of the ECHO Diabetes program to people with diabetes who receive their diabetes care from PCPs. Those matched with a DSC saw clinically significant improvements in hemoglobin A1c and mental health outcomes.

COVID-19 Pandemic Effects on Caregivers of Youth With Type 1 Diabetes: Stress and Self-Efficacy.

Background: Little is known about the coronavirus disease 2019 (COVID-19) pandemic's psychological effects on caregivers of children with type 1 diabetes. Objective: This study aimed to investigate the experience of caregivers of youth with type 1 diabetes during the COVID-19 pandemic. Methods: A 49-item questionnaire using a 5-point Likert scale and open-response questions was distributed via e-mail and type 1 diabetes-related social media platforms from 4 May to 22 June 2020. Quantitative data were analyzed using SPSS v.25 statistical software. Descriptive statistics were used. Relationships were compared using Pearson correlation. Qualitative data were coded and categorized. Results: A total of 272 caregivers participated (mean ± SD respondent age 42.1 ± 7.8 years; 94.5% females; 81.3% with college degree or higher; 52.6% with annual income >$99,000; 80.1% with private insurance). The mean ± SD age of caregivers' children with type 1 diabetes was 11.0 ± 4.1 years, and their mean ± SD diabetes duration was 4.2 ± 3.5 years. Participants reported being diagnosed with or knowing someone with COVID-19 (24.6%), increased stress (71.9%), job loss (10.3%), and financial difficulty (26.8%) as a result of the pandemic. General self-efficacy scores were high (mean ± SD 16.2 ± 2.6, range 8-20) and significantly correlated with COVID-19-related self-efficacy (mean ± SD 12.6 ± 2.1; R = 0.394, P <0.001) and type 1 diabetes self-efficacy during COVID-19 (mean ± SD 17.1 ± 2.5; R = 0.421, P <0.001). Conclusion: Despite reporting high overall self-efficacy, caregivers of children with type 1 diabetes reported greater overall stress and challenges during the pandemic. Health care providers should be prepared to provide families with specific social and mental health support.

Learning experience design of an mHealth self-management intervention for adolescents with type 1 diabetes.

Type 1 diabetes (T1D) is a lifelong and chronic condition that can cause severely compromised health. The T1D treatment regimen is complex, and is a particular challenge for adolescents, who frequently experience a number of treatment adherence barriers (e.g., forgetfulness, planning and organizational challenges, stress). Diabetes Journey is a gamified mHealth program designed to improve T1D self-management through a specific focus on decreasing adherence barriers and improving executive functioning skills for adolescents. Grounded in situativity theory and guided by a sociotechnical-pedagogical usability framework, Diabetes Journey was designed, developed, and evaluated using a learning experience design approach. This approach applied design thinking methods within a Successive Approximation Model design process. Iterative design and formative evaluation were conducted across three design phases, and improvements were implemented following each phase. Findings from the user testing phase indicate Diabetes Journey is a user-friendly mHealth program with high usability that holds promise for enhancing adolescents' T1D self-management. Implications for future designers and researchers are discussed regarding the social dimension of the sociotechnical-pedagogical usability framework. An extension to the framework is proposed to extend the social dimension to include socio-cultural and contextual considerations when designing mHealth applications. Consideration of the pedagogical and sociocultural dimensions of learning is imperative when developing psychoeducational interventions.

Using Peer Power to Reduce Health Disparities: Implementation of a Diabetes Support Coach Program in Federally Qualified Health Centers.

Community health workers (CHWs) provide vital support to underserved communities in the promotion of health equity by addressing barriers related to the social determinants of health that often prevent people living with diabetes from achieving optimal health outcomes. Peer support programs in diabetes can also offer people living with diabetes invaluable support through a shared understanding of the disease and by offsetting diabetes-related stigma. As part of a Project Extension for Community Healthcare Outcomes (ECHO) Diabetes program, participating federally qualified healthcare centers were provided diabetes support coaches (DSCs) to facilitate patient engagement. DSCs hold invaluable expert knowledge, as they live with diabetes themselves and reside in areas they serve, thus combining the CHW role with peer support models. The use of DSCs and CHWs during the coronavirus disease 2019 pandemic and beyond is highly effective at reaching underserved communities with diabetes and promoting health equity.

Democratizing type 1 diabetes specialty care in the primary care setting to reduce health disparities: project extension for community healthcare outcomes (ECHO) T1D.

INTRODUCTION: Project ECHO (Extension for Community Healthcare Outcomes) is a tele-education outreach model that seeks to democratize specialty knowledge to reduce disparities and improve health outcomes. Limited utilization of endocrinologists forces many primary care providers (PCPs) to care for patients with type 1 diabetes (T1D) without specialty support. Accordingly, an ECHO T1D program was developed and piloted in Florida and California. Our goal was to demonstrate the feasibility of an ECHO program focused on T1D and improve PCPs' abilities to manage patients with T1D. RESEARCH DESIGN AND METHODS: Health centers (ie, spokes) were recruited into the ECHO T1D pilot through an innovative approach, focusing on Federally Qualified Health Centers and through identification of high-need catchment areas using the Neighborhood Deprivation Index and provider geocoding. Participating spokes received weekly tele-education provided by the University of Florida and Stanford University hub specialty team through virtual ECHO clinics, real-time support with complex T1D medical decision-making, access to a diabetes support coach, and access to an online repository of diabetes care resources. Participating PCPs completed pre/post-tests assessing diabetes knowledge and confidence and an exit survey gleaning feedback about overall ECHO T1D program experiences. RESULTS: In Florida, 12 spoke sites enrolled with 67 clinics serving >1000 patients with T1D. In California, 11 spoke sites enrolled with 37 clinics serving >900 patients with T1D. During the 6-month intervention, 27 tele-education clinics were offered and n=70 PCPs (22 from Florida, 48 from California) from participating spoke sites completed pre/post-test surveys assessing diabetes care knowledge and confidence in diabetes care. There was statistically significant improvement in diabetes knowledge (p≤0.01) as well as in diabetes confidence (p≤0.01). CONCLUSIONS: The ECHO T1D pilot demonstrated proof of concept for a T1D-specific ECHO program and represents a viable model to reach medically underserved communities which do not use specialists.

Barriers to Technology Use and Endocrinology Care for Underserved Communities With Type 1 Diabetes.

OBJECTIVE: Disparities in type 1 diabetes related to use of technologies like continuous glucose monitors (CGMs) and utilization of diabetes care are pronounced based on socioeconomic status (SES), race, and ethnicity. However, systematic reports of perspectives from patients in vulnerable communities regarding barriers are limited. RESEARCH DESIGN AND METHODS: To better understand barriers, focus groups were conducted in Florida and California with adults ≥18 years old with type 1 diabetes with selection criteria including hospitalization for diabetic ketoacidosis, HbA1c >9%, and/or receiving care at a Federally Qualified Health Center. Sixteen focus groups were conducted in English or Spanish with 86 adults (mean age 42 ± 16.2 years). Transcript themes and pre-focus group demographic survey data were analyzed. In order of frequency, barriers to diabetes technology and endocrinology care included 1) provider level (negative provider encounters), 2) system level (financial coverage), and 3) individual level (preferences). RESULTS: Over 50% of participants had not seen an endocrinologist in the past year or were only seen once including during hospital visits. In Florida, there was less technology use overall (38% used CGMs in FL and 63% in CA; 43% used pumps in FL and 69% in CA) and significant differences in pump use by SES (P = 0.02 in FL; P = 0.08 in CA) and race/ethnicity (P = 0.01 in FL; P = 0.80 in CA). In California, there were significant differences in CGM use by race/ethnicity (P = 0.05 in CA; P = 0.56 in FL) and education level (P = 0.02 in CA; P = 0.90 in FL). CONCLUSIONS: These findings provide novel insights into the experiences of vulnerable communities and demonstrate the need for multilevel interventions aimed at offsetting disparities in diabetes.

Multisite Examination of Depression Screening Scores and Correlates Among Adolescents and Young Adults With Type 2 Diabetes.

OBJECTIVES: Our aim was to evaluate self-reported depressive symptoms and clinical outcomes during routine screening for adolescents and young adults with type 2 diabetes (T2D), and examine associations among depressive symptoms and demographic and clinical characteristics. METHODS: The Patient Health Questionnaire (PHQ) was administered to 197 adolescents and young adults with T2D using the PHQ-2 or PHQ-9 in routine pediatric diabetes care at 4 academic medical centres. Data from electronic health records were extracted from the screening date and 12 months earlier. RESULTS: Adolescents and young adults with T2D (mean age, 16.85 years; 57% male; 77.2% non-Caucasian) completed the PHQ as part of routine diabetes care. On the PHQ, 19.3% of adolescents and young adults endorsed elevated depressive symptoms (PHQ score ≥10) and, among a subsample with item-level data (n=53), 18.9% endorsed thoughts of self-harm. Subsequently, 50.0% of those with depressive symptoms had a documented referral for mental health treatment in the electronic health record after the positive screening outcome. Older age, shorter diabetes duration, higher glycated hemoglobin level, being non-Hispanic white, more blood glucose checks per day and being prescribed oral medications were significantly associated with more depressive symptoms. CONCLUSIONS: Screening for depressive symptoms identifies individuals in need of referral for mental health treatment. A focus on self-harm assessment, standardized methods for documentation of symptoms and mental health referrals and increased referral resources are needed.

A retrospective multisite examination of depression screening practices, scores, and correlates in pediatric diabetes care.

Psychosocial guidelines recommend routine screening of depressive symptoms in adolescents and young adults (AYA) with diabetes. Best practices for screening in routine care and patient characteristics associated with depressive symptoms require further investigation. The purpose of this study was to examine psychometric properties of the Patient Health Questionnaire (PHQ-2 and PHQ-9); document rates of depressive symptoms and related clinical actions; and evaluate associations with patient characteristics. The Patient Health Questionnaire (PHQ-2 or PHQ-9) was administered at five pediatric academic medical centers with 2,138 youth with type 1 diabetes. Screening was part of routine clinical care; retrospective data from electronic health records were collected for the first screening date as well as 12 months prior. The PHQ demonstrated good psychometric properties. Evaluation of item-level PHQ-9 data identified 5.0% of AYA with at least moderate depressive symptoms who would not have been flagged for further screening using the PHQ-2 only. On the PHQ-9, 10.0% of AYA with type 1 diabetes endorsed elevated depressive symptoms and 7.0% endorsed thoughts of self-harm. Patients with moderate or greater depressive symptoms had a 43.9% documented referral rate for mental health treatment. Higher BMI, older age, public insurance, shorter diabetes duration, higher HbA1C, and a diabetic ketoacidosis (DKA) event in the past year were associated with depressive symptoms. The PHQ-9 identified AYA with elevated depressive symptoms that would not have been identified using the PHQ-2. Depressive symptoms were associated with negative diabetes indicators. To improve referral rates, standardized methods for provision and documentation of referrals are needed.

Use of Ecological Momentary Assessment to Measure Self-Monitoring of Blood Glucose Adherence in Youth With Type 1 Diabetes.

OBJECTIVE: Daily self-monitoring of blood glucose (SMBG) is essential for type 1 diabetes management yet is challenging during adolescence. Ecological momentary assessment (EMA) is the repeated sampling of behaviors and experiences in real time in the natural environment. The purpose of this study was to evaluate 1) the validity of self-reported SMBG values via text message-delivered EMA surveys compared with objective SMBG values via glucose meters and 2) in-the-moment motivators and barriers to performing SMBG in a pediatric type 1 diabetes population. METHODS: Youth (n = 62, aged 11-21 years) with type 1 diabetes received three text messages daily for 10 days containing surveys inquiring about SMBG engagement. Objective SMBG values were downloaded from glucose meters. RESULTS: On average, participants reported performing SMBG 4 times/day. Of the self-reported SMBG values, 39.6% were accurate. Inaccurate values included additions (i.e., self-reported value with no objective value), omissions (i.e., objective value with no self-reported value), and alterations (difference between self-report and objective SMBG values ≥10 mg/dL). Of the matched pairs of self-reported and objective SMBG values, 41.3% were altered. Bland-Altman plots determined that the mean difference between self-reported and objective glucose data were -5.43 mg/dL. Participants reported being motivated to check their blood glucose because it was important for their health, and reported barriers included wanting to ignore the task, forgetting, and not having devices. CONCLUSION: Youth's self-reported SMBG values may not align with objective readings. The results of this study can facilitate future research to determine individual factors related to SMBG and accuracy of self-reporting.

Mother and Father Controlling Feeding Behaviors and Associations With Observed Mealtime Family Functioning.

OBJECTIVE: Mealtime family functioning is important in shaping health behaviors associated with overweight/obesity, particularly for preschool-aged children. Parental controlling feeding behaviors (i.e., restriction and pressure to eat), may impact mealtime family functioning and thus be targets of prevention and intervention efforts. The current study aimed to address literature gaps by examining both mother and father self-reports of controlling feeding behaviors, and the discrepancies between parents' reports. Further, the study examined the associations among controlling feeding behaviors and objective mealtime family functioning in a community sample of preschool-aged children. METHODS: The sample included 27 children between 2 and 6 years of age and their immediate family members. Two mealtimes were videotaped for each family and coded for family functioning using the Mealtime Interaction Coding System, and self-reports of feeding practices were collected using the Child Feeding Questionnaire. RESULTS: Mother controlling feeding behaviors were not significantly related to any mealtime family functioning domain. Father controlling feeding behaviors were only significantly related to interpersonal involvement. However, discrepancies in the use of controlling feeding behaviors accounted for nearly one fourth of the variance in overall family functioning and affect management, with greater discrepancies being related to poorer family functioning. CONCLUSIONS: Interventions may be designed to reduce parental discrepancies in the use of controlling feeding behaviors. Future research should consider longitudinal design, using larger, more representative samples, to better understand the impact of parental controlling feeding behaviors, particularly the impact of parental discrepancies in these areas, on mealtime family functioning and subsequent health outcomes.

Designing Online and Mobile Diabetes Education for Fathers of Children With Type 1 Diabetes: Mixed Methods Study.

BACKGROUND: Fathers make unique and central contributions to the health of their children. However, research in type 1 diabetes (T1D) education largely ignores the needs of fathers, including during the development of online and mobile educational materials. OBJECTIVE: The purpose of this study was to solicit and incorporate input from fathers of children with T1D into the design, content, and infrastructure of a suite of online diabetes self-management education and support (DSMES) resources. METHODS: The study took part in three phases: (1) exploratory research, (2) website and subdomain development, and (3) evaluation. Fathers of children with T1D (n=30) completed surveys and semistructured qualitative interviews. Thematic content analysis was used to identify fathers' content and design preferences. An online DSMES website (T1DToolkit.org) and a separate mobile subdomain targeting fathers (Mobile Diabetes Advice for Dads, or mDAD) were developed. A prototype of the site for fathers was evaluated by 33 additional father participants. End user feedback was elicited via survey. RESULTS: Participants in the exploratory phase were enthusiastic about the online diabetes resources. Preferences included high-quality design, availability via mobile phone and tablet, brief text content supplemented with multimedia and interactive features, reminders via text or email, endorsement by medical professionals, and links to scientific evidence. The mDAD subdomain received high usability and acceptability ratings, with 100% of participants very likely or likely to use the site again. CONCLUSIONS: The development of eHealth educational platforms for fathers of children with T1D remains an unmet need in optimizing diabetes management. This study incorporated fathers' feedback into the development of a suite of online diabetes education resources. The findings will serve as the basis for future research to assess the clinical efficacy of the website, its subdomain targeting fathers, and additional subdomains targeting unique populations.

Objectively Measured Adherence in Adolescents With Type 1 Diabetes on Multiple Daily Injections and Insulin Pump Therapy.

Objectives: Type 1 diabetes (T1D) poses unique challenges to adherence-related behavior because of complex treatment regimens that vary by use of specific technologies. This study used objective data to determine (1) prevalence rates of adherence behaviors in adolescents with T1D, and (2) relationships between adherence and glycemic control. Methods: Data were downloaded for the past 30 consecutive days from glucose meters and multiple insulin pump models for 80 youth (11-17 years old; n = 40 on multiple daily injections (MDIs) and n = 40 on continuous subcutaneous insulin infusion [CSII]). Frequency of self-monitoring of blood glucose (SMBG; MDI and CSII users); carbohydrate entry (CSII users); daily insulin bolus delivery (CSII users); episodes of high, very high, and dangerously high hyperglycemia; and correction bolusing for hyperglycemia (CSII users) were calculated. Results: Participants completed SMBG ≥4 times/day on 46.13% of days (MDI users), 48.74% of days (CSII users nonmanual entries only), and 59.07% of days (CSII users; manual plus nonmanual entries). CSII users entered carbohydrates ≥3 times/day on 61.47% of days and bloused insulin ≥3 times/ day on 87.34% of days. Hyperglycemic readings were followed by a correction bolus in <70% of cases. Greater SMBG, carbohydrate entry, bolus insulin delivery, and correction bolusing for high and very high hyperglycemia predicted lower glycated hemoglobin (sample M = 8.74%, SD = 1.75%). Conclusions: Objective data from diabetes technology are helpful to differentiate adherence to specific domains of treatment but are complex in nature. Findings support a need for further research to elucidate predictive factors of suboptimal adherence in adolescents with T1D.

Transition Education for Young Adults With Type 1 Diabetes: Pilot Feasibility Study for a Group Telehealth Intervention.

BACKGROUND: Young adults with type 1 diabetes (T1D) experience a decline in glycemic outcomes and gaps in clinical care. A diabetes education and support program designed for young adults was delivered through group videoconference and mobile Web. OBJECTIVE: The objective of our study was to assess the feasibility, acceptability, and preliminary efficacy of the program as measured by attendance and webpage views, satisfaction, and pre- and postintervention psychosocial outcomes, respectively. METHODS: Young adults aged 18-25 years were recruited to attend five 30-minute group diabetes education videoconferences during an 8-week period. Videoconferences included an expert presentation followed by a moderated group discussion. Within 48 hours of each videoconference, participants were sent a link to more information on the study website. Feasibility was assessed using data on videoconference attendance and webpage views. Acceptability was assessed via a Satisfaction Survey completed at the conclusion of the study. Descriptive statistics were generated. Preliminary efficacy was assessed via a survey to measure changes in diabetes-specific self-efficacy and diabetes distress. Pre- and postintervention data were compared using paired samples t tests. RESULTS: In this study, 20 young adults (mean age 19.2 [SD 1.1] years) attended an average of 5.1 (SD 1.0) videoconferences equivalent to 153 (SD 30.6) minutes of diabetes education per participant during an 8-week period. Average participant satisfaction scores were 62.2 (SD 2.6) out of a possible 65 points. A total of 102 links sent via text message (short message service) or email resulted in 504 webpage views. There was no statistically significant difference between pre- and postintervention diabetes-specific self-efficacy or diabetes-related distress. CONCLUSIONS: Delivery of diabetes education via group videoconference using mobile Web follow-up is feasible and acceptable to young adults with T1D. This model of care delivery has the potential to improve attendance, social support, and patient-reported satisfaction. Nevertheless, further research is required to establish the effect on long-term psychosocial and glycemic outcomes.

Telehealth interventions to reduce management complications in type 1 diabetes: A review.

Type 1 diabetes is a chronic illness with a high burden of care. While effective interventions and recommendations for diabetes care exist, the intensive nature of diabetes management makes compliance difficult. This is especially true in children and adolescents as they have unique psychosocial and diabetes needs. Despite the development of effective in-person interventions targeting improving self-management and ameliorating psychosocial difficulties there are still a number of barriers to implementing these interventions, namely time, cost, and access. Telehealth interventions allow for the dissemination of these interventions to a broader audience. Self-management and psychosocial telehealth interventions are reviewed with a special emphasis on mobile phone and internet based technology use. While efficacy has been demonstrated in a number of telehealth interventions with improved cost effectiveness over in-person interventions, many challenges remain including high participant attrition and difficulties with receiving reimbursement for services rendered. These and other challenges are discussed with recommendations for researchers and telehealth providers provided.

Systematic review and meta-analysis of comprehensive behavioral family lifestyle interventions addressing pediatric obesity.

PURPOSE: To conduct a meta-analysis of randomized controlled trials examining the efficacy of comprehensive behavioral family lifestyle interventions (CBFLI) for pediatric obesity. METHOD: Common research databases were searched for articles through April 1, 2013. 20 different studies (42 effect sizes and 1,671 participants) met inclusion criteria. Risk of bias assessment and rating of quality of the evidence were conducted. RESULTS: The overall effect size for CBFLIs as compared with passive control groups over all time points was statistically significant (Hedge's g = 0.473, 95% confidence interval [.362, .584]) and suggestive of a small effect size. Duration of treatment, number of treatment sessions, the amount of time in treatment, child age, format of therapy (individual vs. group), form of contact, and study use of intent to treat analysis were all statistically significant moderators of effect size. CONCLUSION: CBFLIs demonstrated efficacy for improving weight outcomes in youths who are overweight or obese.

The role of overweight perception and depressive symptoms in child and adolescent unhealthy weight control behaviors: a mediation model.

OBJECTIVE: Children who are overweight or obese are at risk for depression and development of unhealthy weight control behaviors (UWCBs), including using diet pills, purging, or fasting. Explications of pathways leading to UWCBs are needed to prevent the associated negative health outcomes. METHODS: Participants were 106 children/adolescents 8-17 years of age at a pediatric clinic. Measures included child body mass index, the Child Depression Inventory-Short Form, and questionnaires assessing perception of overweight and UWCBs used in the past year. Depression was hypothesized to mediate the relationship between perception of overweight and UWCBs. RESULTS: A bootstrapped mediation model revealed that depressive symptoms mediated the relationship between youth perception of overweight and UWCBs accounting for youth body mass index z-score. The total model explained 24% of the variance in UWCBs. Discussion This study presents a potential mechanism by which youth perception of overweight may influence UWCBs. Longitudinal research is needed to further elucidate the directionality of these relationships.

Self-Reported Recent Life Stressors and Risk of Suicide in Pediatric Emergency Department Patients.

Emergency departments (EDs) are important venues for detecting youth at risk for suicide. Children and adolescents who present to the ED and report a recent life stressor, such as stressors related to interpersonal relationships, may be at elevated risk for suicide. Utilizing data from three large, urban pediatric EDs, we examined the relationship between reported recent life stressors and suicide risk, as measured by the Suicidal Ideation Questionnaire. Overall, youth who reported a recent life stressor were at elevated risk of suicide [adjOR = 5.43 (95% CI, 3.18-9.26)]. Importantly, however, this finding was tempered by the fact that 20% of youth who screened positive for suicide risk did not report a stressor. Thus, while the knowledge of stressors may provide useful supplementary information to a suicide risk assessment, the presence or absence of a reported stressor is not sufficient to determine one's risk of suicide. ED clinicians are advised to include direct questions about suicidal thoughts and behaviors.