Intensive education improves glycemic outcomes in new-onset type 1 diabetes

February 16, 2022

3 minutes of reading


Source / Disclosure


Disclosure: Maahs reports that it has received research support from the Helmsley Charitable Foundation, JDRF, the National Science Foundation and the NIH, and has advised Abbott, Eli Lilly, the Helmsley Charitable Foundation, Insulet, Novo Nordisk and Sanofi. The Maas facility has received research support from Bigfoot Biomedical, Dexcom, Insulet, Medtronic, Roche and Tandem. Please read the study to learn about the financial information of other authors.


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According to the study, intensive training in diabetes with early onset of continuous glucose monitoring is associated with improved HbA1c in children with type 1 diabetes.

Researchers at Stanford University have introduced the 4T program – teamwork, goals, technology and tight control – to focus more on treating diabetes in children with type 1 diabetes, which first appeared. Participants in the 4T program had lower mean HbA1c levels at 6, 9, and 12 months post-diagnosis compared with the group of children with type 1 diabetes who received standard diabetes education.


David M. Maahs, MD
Maahs head of the Department of Pediatric Endocrinology at Stanford Children’s Health.

“Early onset of CGM shortly after diagnosis of type 1 diabetes was well received by patients and families and resulted in 0.5% lower HbA1c compared with historical control groups,” David M. Maahs, MD, Healio was told by the head of the pediatric endocrinology department of Stanford Children’s Health. “The use of remote monitoring and a population panel has allowed certified diabetes educators to asynchronously monitor glucose levels and provide diabetes training and dose adjustment in between clinical visits.”

Maach and his colleagues enrolled 135 children diagnosed with type 1 diabetes at Stanford Children’s Center from July 2018 to June 2020 in the 4T program (mean age 9.7 years; 52.6% boys; 37% white). Those who decided to start CGM had a follow-up visit with a certified diabetes care and education specialist to begin the technology. Persons diagnosed in March 2019 or later (n = 89) were also admitted to participate in remote monitoring. CGM data were transferred to electronic medical records and viewed weekly. Certified diabetes care and education professionals have recommended adjusting the insulin dose if necessary. Changes in HbA1c 4 to 12 months post-diagnosis in the 4T cohort were compared with a historical cohort of 272 children diagnosed with type 1 diabetes between June 2014 and December 2016 who received standard diabetes education and quarterly visits (average age 9.7 years). ; 50.4% of boys; 42.6% white).

The findings were published in Journal of Clinical Endocrinology & Metabolism.

The 4T program improves glycemic performance

The 4T program group had higher HbA1c levels at baseline compared to the historical group (12.2% vs. 10.7%), but there were no other significant differences between the cohorts. The historical group had an increase in HbA1c levels after 4 months, with HbA1c steadily increasing over time, whereas in the 4T program group there was a more gradual increase in HbA1c. The 4T program cohort had a mean HbA1c level 0.54% lower at 6 months, 0.52% lower at 9 months, and 0.58% lower at 12 months compared to the historical period cohort. The mean HbA1c increased between 4 and 12 months by 1.47% in the historical group compared to 1.32% in the 4T program group (P <0.001).

In the 4T cohort, children who did not participate in remote monitoring had earlier and faster growth of HbA1c compared with those who had remote monitoring, although both groups had lower HbA1c at 12 months compared with the historical cohort. In those who had remote monitoring, the mean HbA1c was 0.14% lower after 6 months, 0.18% lower after 9 months, and 0.14% lower after 12 months compared with 4T participants without remote control.

After 3 months, the historical cohort had a higher proportion of children achieving the HbA1c target of less than 7.5%. After 12 months in the 4T cohort, the percentage of children with HbA1c was less than 7.5% compared with the historical group (66% vs. 43%; P <0.01).

“I was not surprised, but satisfied [by] how positively early access and CGM education for children and families is affected, ”Maahs said. “We were also very pleased that all patients, regardless of private or public insurance, English-speaking or not, were able to attend and benefit from the program.”

Overcoming barriers

The glucose control indicator was calculated at 2-week intervals due to the fact that some participants did not allow HbA1c data due to the COVID-19 pandemic. The patterns of glucose control indicators in the 4T program group were similar to those observed with HbA1c, with the lowest value occurring 10–20 weeks after diagnosis. The time in the range was also highest between 10 and 20 weeks and slowly decreased during the study. The mean time range for the 4T program group was 66% throughout the study and 63% after 12 months.

The results showed that the 4T program could improve glycemic performance, but Maahs said there were several barriers that needed to be removed to allow the program to be implemented in other clinics.

“Transmitting data for use can be a big challenge, and we’re lucky that Stanford has a great team of engineers and data scientists who are very important to the program,” Maahs said. “We are committed to developing and sharing this dashboard system, Timely Interventions in Diabetes Excellence, with other programs. In addition, many programs do not have sufficient support from certified diabetes care and education professionals to provide as much education as they would like. Similarly, certified diabetes care and education professionals spend too much time processing insurance documents instead of educating and caring for patients. ”

For more information:

David M. Maahs, MD, available at dmaahs@stanford.edu.

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