Dr. Ananta Addala is a pediatric endocrinologist and physician scientist addressing disparities in pediatric type 1 diabetes management and outcomes. As a physician with a background in pediatric endocrinology, epidemiology, and behavioral health, she aims to build an evidence-based approach to addressing T1D disparities by systematically evaluating youth-, family-, provider-, and system-level barriers to optimal diabetes care in youth from low socioeconomic and racial/ethnic minority groups.

To date, her publications have demonstrated that the disparities in pediatric T1D by socioeconomic status are worsening in the US, provider bias against public insurance is common, and public insurance mediated interruptions to diabetes technology adversely impact glycemic outcomes. She has also been leading the efforts to improve justice, equity, diversity, and inclusion in research at Stanford University through her leadership at Stanford Pediatrics Advancing Anti-Racism Coalition and as the co-chair of TrialNet's Underrepresented Minorities Outreach Committee.

Clinical Focus

  • Pediatric Endocrinology

Academic Appointments

Honors & Awards

  • Clinical Science Research Award, Stanford University Department of Pediatrics (06/2023)
  • Young Investigator Award, International Society for Pediatric and Adolescent Diabetes (10/2022)
  • Advocacy Award, Stanford University Department of Pediatrics (06/2021)

Professional Education

  • Board Certification: American Board of Pediatrics, Pediatric Endocrinology (2021)
  • Fellowship: Stanford University Pediatric Endocrinology Fellowship (2020) CA
  • Residency: LACplusUSC Pediatric Residency (2017) CA
  • Board Certification: American Board of Pediatrics, Pediatrics (2016)
  • Medical Education: University of New England College of Osteopathic Medicine (2013) ME

Clinical Trials

  • BEAD-T1D: Building the Evidence to Address Disparities in Type 1 Diabetes Recruiting

    Youth from low socioeconomic groups are at a systematic disadvantage in the provision of diabetes care, particularly diabetes technology which is associated with improvement in diabetes-specific outcomes. Thus, the type 1 diabetes community urgently need studies to understand and ameliorate the persistent worsening of disparities of diabetes management and outcomes in youth from low socioeconomic backgrounds. This proposed research will (1) improve representation of diverse youth in the literature, (2) address the gap in knowledge of barriers and promoters in publicly insured youth, and (3) identify and address factors of worsening disparity in diabetes technology.

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2023-24 Courses

All Publications

  • Digital Technology for Diabetes. Reply. The New England journal of medicine Hughes, M. S., Addala, A., Buckingham, B. 2024; 390 (10): 963-964

    View details for DOI 10.1056/NEJMc2315000

    View details for PubMedID 38446694

  • Intersectional identities play a role in perceived discrimination for families living with type 1 diabetes. Diabetes research and clinical practice Addala, A., Medina Penaranda, R., Naranjo, D., Maahs, D. M., Hood, K. K. 2024: 111568

    View details for DOI 10.1016/j.diabres.2024.111568

    View details for PubMedID 38364908

  • Making a Good Thing Even Better: Expanding Access and Applicability of Automated Insulin Delivery Systems to Benefit All Youth With Type 1 Diabetes. Diabetes care Addala, A. 2023; 46 (12): 2126-2128

    View details for DOI 10.2337/dci23-0057

    View details for PubMedID 38011525

  • Digital Technology for Diabetes. The New England journal of medicine Hughes, M. S., Addala, A., Buckingham, B. 2023; 389 (22): 2076-2086

    View details for DOI 10.1056/NEJMra2215899

    View details for PubMedID 38048189

  • Recruiting historically under-represented individuals into Project ECHO Diabetes: using barrier analysis to understand disparities in clinical research in the USA. BMJ open Addala, A., Hechavarria, M., Figg, L., Roque, X., Filipp, S. L., Anez-Zabala, C., Lal, R., Gurka, M. J., Haller, M. J., Maahs, D. M., Walker, A. F. 2023; 13 (8): e072546


    Individuals under-recruited in diabetes research studies include those not seen at endocrinology centres and those from rural, low socioeconomic and/or under-represented racial/ethnic groups. The purpose of this descriptive analysis is to detail recruitment and retention efforts of Project ECHO Diabetes clinical sites affiliated with Stanford University and University of Florida.Prospective collection of participant engagement and qualitative analysis of barriers and facilitators of research engagement within Project ECHO Diabetes, a virtual tele-education programme for healthcare providers in the management of individuals with insulin-requiring diabetes.Data were collected at the patient level, provider level and clinic level between 1 May 2021 and 31 July 2022.Participants and study personnel were recruited from 33 Project ECHO Diabetes sites in California and Florida.We report study completion rates for participants recruited into 33 Project ECHO Diabetes sites. Using barrier analysis, a methodology designed for the real-time assessment of interventions and system processes to identify barriers and facilitators, study personnel identified significant barriers to recruitment and retention and mapped them to actionable solutions.In total, 872 participants (California n=495, Florida n=377) were recruited with differing recruitment rates by site (California=52.7%, Florida=21.5%). Barrier analysis identified lack of trust, unreliable contact information, communication issues and institutional review board (IRB) requirements as key recruitment barriers. Culturally congruent staff, community health centre (CHC) support, adequate funding and consent process flexibility were solutions to address recruitment challenges. Barriers to retention were inconsistent postal access, haemoglobin A1c kit collection challenges, COVID-19 pandemic and broadband/connectivity issues. Additional funding supporting research staff and analogue communication methods were identified as solutions address barriers to retention.Funded partnerships with CHCs, trusted by their local communities, were key in our recruitment and retention strategies. IRB consent process flexibility reduced barriers to recruitment. Recruiting historically under-represented populations is feasible with funding aimed to address structural barriers to research participation.

    View details for DOI 10.1136/bmjopen-2023-072546

    View details for PubMedID 37648378

  • Disparities in Hemoglobin A1c Levels in the First Year After Diagnosis Among Youths With Type 1 Diabetes Offered Continuous Glucose Monitoring. JAMA network open Addala, A., Ding, V., Zaharieva, D. P., Bishop, F. K., Adams, A. S., King, A. C., Johari, R., Scheinker, D., Hood, K. K., Desai, M., Maahs, D. M., Prahalad, P. 2023; 6 (4): e238881


    Continuous glucose monitoring (CGM) is associated with improvements in hemoglobin A1c (HbA1c) in youths with type 1 diabetes (T1D); however, youths from minoritized racial and ethnic groups and those with public insurance face greater barriers to CGM access. Early initiation of and access to CGM may reduce disparities in CGM uptake and improve diabetes outcomes.To determine whether HbA1c decreases differed by ethnicity and insurance status among a cohort of youths newly diagnosed with T1D and provided CGM.This cohort study used data from the Teamwork, Targets, Technology, and Tight Control (4T) study, a clinical research program that aims to initiate CGM within 1 month of T1D diagnosis. All youths with new-onset T1D diagnosed between July 25, 2018, and June 15, 2020, at Stanford Children's Hospital, a single-site, freestanding children's hospital in California, were approached to enroll in the Pilot-4T study and were followed for 12 months. Data analysis was performed and completed on June 3, 2022.All eligible participants were offered CGM within 1 month of diabetes diagnosis.To assess HbA1c change over the study period, analyses were stratified by ethnicity (Hispanic vs non-Hispanic) or insurance status (public vs private) to compare the Pilot-4T cohort with a historical cohort of 272 youths diagnosed with T1D between June 1, 2014, and December 28, 2016.The Pilot-4T cohort comprised 135 youths, with a median age of 9.7 years (IQR, 6.8-12.7 years) at diagnosis. There were 71 boys (52.6%) and 64 girls (47.4%). Based on self-report, participants' race was categorized as Asian or Pacific Islander (19 [14.1%]), White (62 [45.9%]), or other race (39 [28.9%]); race was missing or not reported for 15 participants (11.1%). Participants also self-reported their ethnicity as Hispanic (29 [21.5%]) or non-Hispanic (92 [68.1%]). A total of 104 participants (77.0%) had private insurance and 31 (23.0%) had public insurance. Compared with the historical cohort, similar reductions in HbA1c at 6, 9, and 12 months postdiagnosis were observed for Hispanic individuals (estimated difference, -0.26% [95% CI, -1.05% to 0.43%], -0.60% [-1.46% to 0.21%], and -0.15% [-1.48% to 0.80%]) and non-Hispanic individuals (estimated difference, -0.27% [95% CI, -0.62% to 0.10%], -0.50% [-0.81% to -0.11%], and -0.47% [-0.91% to 0.06%]) in the Pilot-4T cohort. Similar reductions in HbA1c at 6, 9, and 12 months postdiagnosis were also observed for publicly insured individuals (estimated difference, -0.52% [95% CI, -1.22% to 0.15%], -0.38% [-1.26% to 0.33%], and -0.57% [-2.08% to 0.74%]) and privately insured individuals (estimated difference, -0.34% [95% CI, -0.67% to 0.03%], -0.57% [-0.85% to -0.26%], and -0.43% [-0.85% to 0.01%]) in the Pilot-4T cohort. Hispanic youths in the Pilot-4T cohort had higher HbA1c at 6, 9, and 12 months postdiagnosis than non-Hispanic youths (estimated difference, 0.28% [95% CI, -0.46% to 0.86%], 0.63% [0.02% to 1.20%], and 1.39% [0.37% to 1.96%]), as did publicly insured youths compared with privately insured youths (estimated difference, 0.39% [95% CI, -0.23% to 0.99%], 0.95% [0.28% to 1.45%], and 1.16% [-0.09% to 2.13%]).The findings of this cohort study suggest that CGM initiation soon after diagnosis is associated with similar improvements in HbA1c for Hispanic and non-Hispanic youths as well as for publicly and privately insured youths. These results further suggest that equitable access to CGM soon after T1D diagnosis may be a first step to improve HbA1c for all youths but is unlikely to eliminate disparities Identifier: NCT04336969.

    View details for DOI 10.1001/jamanetworkopen.2023.8881

    View details for PubMedID 37074715

    View details for PubMedCentralID PMC10116368

  • Sparking a Movement, Not a Moment: Framework and Outcomes from a Pediatrics Department-Wide Coalition to Advance Anti-Racism: Running Title: Pediatrics Department Coalition to Advance Anti-Racism. Academic pediatrics Yemane, L., Ramirez, M., Guerin, A., Floyd, B., Okorie, C. U., Ling, W., Addala, A., Figg, L., Talley, E. M., Chamberlain, L. 2022


    BACKGROUND: The Stanford Pediatrics Advancing Anti-Racism Coalition (SPAARC) was created to promote a culture of anti-racism through immediate action, development of nimble systems, and longitudinal commitment towards equity.OBJECTIVE: Evaluate gaps in the Stanford Department of Pediatrics (DoP) efforts to advance anti-racism and form a coalition of faculty, staff, and trainees to prioritize, design, and implement targeted activities with immediate and long-term measurable outcomes.METHODS: A needs assessment was conducted across all DoP members in July-August 2020 to identify gaps in anti-racism efforts. Listening sessions were recorded and transcribed to extrapolate key themes and two rounds of consensus surveys were done to identify and prioritize actions. Actions teams were created and co-led by faculty-staff dyads with trainee representation. A final activity survey was conducted in January 2021 to determine the specific activities (i.e., interventions) each team would design and implement.RESULTS: Ten small group listening sessions (70 participants) and three surveys (1005 responses) led to the creation of seven action teams with associated activities (1) training (2) community engagement and research (3) communication (4) faculty and staff recruitment and advancement (5) leadership representation (6) human resources, and (7) staff engagement. 443 (41%) DoP members were directly involved in SPAARC through participation in the needs assessment, action teams, and/or implementation of activities.CONCLUSION: SPAARC can serve as an adaptable framework for how a DoP can create a coalition to identify gaps in anti-racism efforts and create and implement targeted activities with associated outcomes.

    View details for DOI 10.1016/j.acap.2022.10.003

    View details for PubMedID 36216211

  • Implicit Racial-Ethnic and Insurance Mediated Bias to Recommending Diabetes Technology: Insights from T1D Exchange Multi-Center Pediatric and Adult Diabetes Provider Cohort. Diabetes technology & therapeutics Odugbesan, O., Addala, A., Nelson, G., Hopkins, R., Cossen, K., Schmitt, J., Indyk, J., Jones, N. Y., Agarwal, S., Rompicherla, S., Ebekozien, O. 2022


    Background Despite documented benefits of diabetes technology in managing type 1 diabetes, inequities persist in the use of these devices. Provider bias may be a driver of inequities, but the evidence is limited. Therefore, we aimed to examine the role of race/ethnicity and insurance-mediated provider implicit bias in recommending diabetes technology.METHOD: We recruited one hundred and nine adult and pediatric diabetes providers across seven US endocrinology centers to complete an implicit bias assessment comprised of a clinical vignette and ranking exercise. Providers were randomized to receive clinical vignettes with differing insurance and patient names as proxy for Racial-Ethnic identity. Bias was identified if providers: 1) recommended more technology for patients with an English name (Racial-Ethnic bias) or private insurance (insurance bias), or 2) Race-Ethnicity or insurance was ranked high (Racial-Ethnic and insurance bias, respectively) in recommending diabetes technology. Provider characteristics were analyzed using descriptive statistics and multivariate logistic regression.RESULT: Insurance-mediated implicit bias was common in our cohort (n=66, 61%). Providers who were identified to have insurance-mediated bias had greater years in practice (5.3±5.3 years vs. 9.3±9 years, p=0.006). Racial-Ethnic mediated implicit bias was also observed in our study (n=37, 34%). Compared to those without Racial-Ethnic bias, providers with Racial-Ethnic bias were more likely to state that they could recognize their own implicit bias (89% vs. 61%, p =0.001).CONCLUSION: Provider implicit bias to recommend diabetes technology was observed based on insurance and Race-Ethnicity in our pediatric and adult diabetes provider cohort. This data raises the need to address provider implicit bias in diabetes care.

    View details for DOI 10.1089/dia.2022.0042

    View details for PubMedID 35604789

  • Provider Implicit Bias Impacts Pediatric Type 1 Diabetes Technology Recommendations in the United States: Findings from The Gatekeeper Study. Journal of diabetes science and technology Addala, A., Hanes, S., Naranjo, D., Maahs, D. M., Hood, K. K. 2021: 19322968211006476


    BACKGROUND: Diabetes technology use is associated with favorable type 1 diabetes (T1D) outcomes. American youth with public insurance, a proxy for low socioeconomic status, use less diabetes technology than those with private insurance. We aimed to evaluate the role of insurance-mediated provider implicit bias, defined as the systematic discrimination of youth with public insurance, on diabetes technology recommendations for youth with T1D in the United States.METHODS: Multi-disciplinary pediatric diabetes providers completed a bias assessment comprised of a clinical vignette and ranking exercises (n=39). Provider bias was defined as providers: (1) recommending more technology for those on private insurance versus public insurance or (2) ranking insurance in the top 2 of 7 reasons to offer technology. Bias and provider characteristics were analyzed with descriptive statistics, group comparisons, and multivariate logistic regression.RESULTS: The majority of providers [44.1±10.0years old, 83% female, 79% non-Hispanic white, 49% physician, 12.2±10.0 practice-years] demonstrated bias (n=33/39, 84.6%). Compared to the group without bias, the group with bias had practiced longer (13.4±10.4years vs 5.7±3.6years, P=.003) but otherwise had similar characteristics including age (44.4±10.2 vs 42.6±10.1, p=0.701). In the logistic regression, practice-years remained significant (OR=1.47, 95% CI [1.02,2.13]; P=.007) when age, sex, race/ethnicity, provider role, percent public insurance served, and workplace location were included.CONCLUSIONS: Provider bias to recommend technology based on insurance was common in our cohort and increased with years in practice. There are likely many reasons for this finding, including healthcare system drivers, yet as gatekeepers to diabetes technology, providers may be contributing to inequities in pediatric T1D in the United States.

    View details for DOI 10.1177/19322968211006476

    View details for PubMedID 33858206

  • Cost considerations for adoption of diabetes technology are pervasive: a qualitative study of persons living with type 1 diabetes and their families. Diabetic medicine : a journal of the British Diabetic Association Addala, A., Suttiratana, S. C., Wong, J. J., Lanning, M. S., Barnard, K. D., Weissberg-Benchell, J., Laffel, L. M., Hood, K. K., Naranjo, D. 2021: e14575


    BACKGROUND: Cost is a major consideration in the uptake and continued use of diabetes technology. With increasing use of automated insulin delivery systems, it is important to understand the specific cost-related barriers to technology adoption. In this qualitative analysis, we were interested in understanding and examining the decision-making process around cost and diabetes technology use.MATERIALS AND METHODS: Four raters coded transcripts of four stakeholder groups using inductive coding for each stakeholder group to establish relevant themes/nodes. We applied the Social Ecological Model in the interpretation of five thematic levels of cost.RESULTS: We identified five thematic levels of cost: policy, organizational, insurance, interpersonal, and individual. Equitable diabetes technology access was an important policy-level theme. The insurance-level theme had multiple sub-themes which predominantly carried a negative valence. Participants also emphasized the psychosocial burden of cost specifically identifying diabetes costs to their families, the guilt of diabetes related costs, and frustration in the time and involvement required to ensure insurance coverage.CONCLUSION: We found broad consensus in how cost is experienced by stakeholder groups. Cost considerations for diabetes technology uptake extended beyond finances to include time, cost to society, morality, and interpersonal relationships. Cost also reflected an important moral principle tied to the shared desire for equitable access to diabetes technology. Knowledge of these considerations can help clinicians and researchers promote equitable device uptake while anticipating barriers for all persons living with type 1 diabetes and their families.

    View details for DOI 10.1111/dme.14575

    View details for PubMedID 33794006

  • A Decade of Disparities in Diabetes Technology Use and HbA1c in Pediatric Type 1 Diabetes: A Transatlantic Comparison. Diabetes care Addala, A., Auzanneau, M., Miller, K., Maier, W., Foster, N., Kapellen, T., Walker, A., Rosenbauer, J., Maahs, D. M., Holl, R. W. 2020


    OBJECTIVE: As diabetes technology use in youth increases worldwide, inequalities in access may exacerbate disparities in hemoglobin A1c (HbA1c). We hypothesized that an increasing gap in diabetes technology use by socioeconomic status (SES) would be associated with increased HbA1c disparities.RESEARCH DESIGN AND METHODS: Participants aged <18 years with diabetes duration ≥1 year in the Type 1 Diabetes Exchange (T1DX, U.S., n = 16,457) and Diabetes Prospective Follow-up (DPV, Germany, n = 39,836) registries were categorized into lowest (Q1) to highest (Q5) SES quintiles. Multiple regression analyses compared the relationship of SES quintiles with diabetes technology use and HbA1c from 2010-2012 to 2016-2018.RESULTS: HbA1c was higher in participants with lower SES (in 2010-2012 and 2016-2018, respectively: 8.0% and 7.8% in Q1 and 7.6% and 7.5% in Q5 for DPV; 9.0% and 9.3% in Q1 and 7.8% and 8.0% in Q5 for T1DX). For DPV, the association between SES and HbA1c did not change between the two time periods, whereas for T1DX, disparities in HbA1c by SES increased significantly (P < 0.001). After adjusting for technology use, results for DPV did not change, whereas the increase in T1DX was no longer significant.CONCLUSIONS: Although causal conclusions cannot be drawn, diabetes technology use is lowest and HbA1c is highest in those of the lowest SES quintile in the T1DX, and this difference for HbA1c broadened in the past decade. Associations of SES with technology use and HbA1c were weaker in the DPV registry.

    View details for DOI 10.2337/dc20-0257

    View details for PubMedID 32938745

  • Uninterrupted Continuous Glucose Monitoring Access is Associated with a Decrease in HbA1c in Youth with Type 1 Diabetes and Public Insurance. Pediatric diabetes Addala, A., Maahs, D. M., Scheinker, D., Chertow, S., Leverenz, B., Prahalad, P. 2020


    OBJECTIVE: Continuous glucose monitor (CGM) use is associated with improved glucose control. We describe the effect of continued and interrupted CGM use on hemoglobin A1c (HbA1c) in youth with public insurance.METHODS: We reviewed 956 visits from 264 youth with type 1 diabetes (T1D) and public insurance. Demographic data, HbA1c and two-week CGM data were collected. Youth were classified as never user, consistent user, insurance discontinuer, and self-discontinuer. Visits were categorized as never-user visit, visit before CGM start, visit after CGM start, visit with continued CGM use, visit with initial loss of CGM, visit with continued loss of CGM, and visit where CGM is regained after loss. Multivariate regression adjusting for age, sex, race, diabetes duration, initial HbA1c, and BMI were used to calculate adjusted mean and delta HbA1c.RESULTS: Adjusted mean HbA1c was lowest for the consistent user group (HbA1c 8.6%;[95%CI 7.9,9.3]). Delta HbA1c (calculated from visit before CGM start) was lower for visit after CGM start (-0.39%;[95%CI -0.78,-0.02]) and visit with continued CGM use (-0.29%;[95%CI -0.61,0.02]) whereas it was higher for visit with initial loss of CGM (0.40%;[95%CI -0.06,0.86]), visit with continued loss of CGM (0.46%;[95%CI 0.06,0.85]), and visit where CGM is regained after loss (0.57%;[95%CI 0.06,1.10]).CONCLUSIONS: Youth with public insurance using CGM have improved HbA1c, but only when CGM use is uninterrupted. Interruptions in use, primarily due to gaps in insurance coverage of CGM, were associated with increased HbA1c. These data support both initial and ongoing coverage of CGM for youth with T1D and public insurance. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1111/pedi.13082

    View details for PubMedID 32681582

  • COVID-19 impacts and inequities among underserved communities with diabetes. Journal of clinical & translational endocrinology Maizel, J. L., Haller, M. J., Maahs, D. M., Addala, A., Lal, R. A., Filipp, S. L., Gurka, M. J., Westen, S., Dixon, B. N., Figg, L., Hechavarria, M., Malden, K. G., Walker, A. F. 2024; 36: 100337


    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.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.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).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.

    View details for DOI 10.1016/j.jcte.2024.100337

    View details for PubMedID 38559803

    View details for PubMedCentralID PMC10973684

  • Equity in type 1 diabetes technology and beyond: where are we in 2022? FRONTIERS IN ENDOCRINOLOGY Burckhardt, M., Addala, A., de Bock, M. 2024; 15: 1400240

    View details for DOI 10.3389/fendo.2024.1400240

    View details for Web of Science ID 001198627000001

    View details for PubMedID 38596223

    View details for PubMedCentralID PMC11002255

  • Diabetes Technology in the "Real World": Expanding Access and Addressing Disparities. Diabetes technology & therapeutics Addala, A., Weinzimer, S. A. 2024; 26 (S1): S187-S200

    View details for DOI 10.1089/dia.2024.2512

    View details for PubMedID 38441450

  • "It changed everything we do": A mixed methods study of youth and parent experiences with a pilot exercise education intervention following new diagnosis of type 1 diabetes. Journal of diabetes and its complications Tanenbaum, M. L., Addala, A., Hanes, S., Ritter, V., Bishop, F. K., Cortes, A. L., Pang, E., Hood, K. K., Maahs, D. M., Zaharieva, D. P. 2023; 38 (1): 108651


    This pilot study delivered a comprehensive exercise education intervention to youth with new-onset type 1 diabetes (T1D) and their parents to increase knowledge and confidence with physical activity (PA) shortly after diagnosis.Youth initiated continuous glucose monitoring (CGM) and PA trackers within 1 month of diagnosis. Youth and their parents received the 4-session intervention over 12 months. Participants completed self-report questionnaires at baseline, 6- and 12-months. Surveys were analyzed using linear mixed effects models. Semi-structured interviews and focus groups explored experiences with the exercise education intervention. Groups and interviews were audio-recorded, transcribed, and analyzed using content analysis.A total of 16 parents (aged 46 ± 7 years; 88 % female; 67 % non-Hispanic White) and 17 youth (aged 14 ± 2 years; 41 % female; 65 % non-Hispanic White) participated. Worry about hypoglycemia did not worsen throughout the study duration. Parents and youth reported increased knowledge and confidence in managing T1D safely and preventing hypoglycemia during PA following receiving the tailored exercise education intervention.This study assessed a novel structured exercise education program for youth and their parents shortly following T1D diagnosis. These results support the broad translation and acceptability of a structured exercise education program in new-onset T1D.

    View details for DOI 10.1016/j.jdiacomp.2023.108651

    View details for PubMedID 38043358

  • Following in Banting's footsteps or straying from the path? Observations from contemporary diabetes innovation. Frontiers in endocrinology Leadley, C., Addala, A., Berkeley, J., Crocket, H., Davis, E. A., Hewapathirana, N., Hussain, S., Lal, R., Lomax, K., Wilkinson, T., de Bock, M., Burckhardt, M. A. 2023; 14: 1270517


    While advancements in the treatment of diabetes continue to rapidly evolve, many of the newer technologies have financial barriers to care, opposing the egalitarian ethos of Banting who sold his patent on insulin for a nominal cost to allow it to be made widely available. Inequity in access to new therapies drives disparity in diabetes burden with potential for these gaps to widen in the future. The 2023 International Conference on Advanced Technologies and Treatments of Diabetes (ATTD) presented ground-breaking and current research in diabetes technology. Oral presentations of the ATTD conference 2023 were analyzed to describe what percentage of speakers discussed equity in their talks. Overall, less than a quarter of presenters discussed equity, though there was regional variation. To ensure that diabetes technologies reduce disparity and improve outcomes, we encourage future speakers at diabetes (technology) conferences to consider equity of diabetes care and incorporate this into their presentations.

    View details for DOI 10.3389/fendo.2023.1270517

    View details for PubMedID 38033993

    View details for PubMedCentralID PMC10686253

  • Diabetic ketoacidosis (DKA) at diagnosis in youth with type 1 diabetes (T1D) is associated with a higher hemoglobin A1c even with intensive insulin management. Diabetes technology & therapeutics Zaharieva, D. P., Ding, V., Addala, A., Prahalad, P., Bishop, F., Hood, K., Desai, M., Wilson, D. M., Buckingham, B. A., Maahs, D. M. 2023


    Diabetic ketoacidosis (DKA) at diagnosis is associated with short- and long-term complications. We assessed the relationship between DKA status and hemoglobin A1c (A1c) levels in the first year following type 1 diabetes (T1D) diagnosis.The Pilot 4T study offered continuous glucose monitoring to youth with T1D within 1 month of diagnosis. A1c levels were compared between historical (n=271) and Pilot 4T (n=135) cohorts stratified by DKA status at diagnosis (DKA: historical=94, 4T=67 vs without DKA historical=177, 4T=68). A1c was evaluated using locally estimated scatter plot smoothing. Change in A1c from 4- to 12-months post-diagnosis was evaluated using a linear mixed model.Median age was 9.7 [IQR: 6.6, 12.7] vs 9.7 [IQR: 6.8, 12.7] years, 49% vs 47% female, 44% vs 39% Non-Hispanic White in historical vs Pilot 4T. In historical and 4T cohorts, DKA at diagnosis demonstrated higher A1c at 6 (0.5% [95%CI: 0.21, 0.79; p<0.01] and 0.38% [95% CI: 0.02, 0.74; p=0.04], respectively) and 12 months (0.62% [95% CI: -0.06, 1.29; p=0.07] and 0.39% [95% CI: -0.32, 1.10; p=0.29], respectively). The highest % time in range (TIR; 70-180 mg/dL) was seen between weeks 15-20 (69%) vs 25-30 (75%) post-diagnosis for youth with vs without DKA in Pilot 4T, respectively.Pilot 4T improved A1c outcomes vs the historical cohort, but those with DKA at diagnosis had persistently elevated A1c throughout the study and intensive diabetes management did not mitigate this difference. DKA prevention at diagnosis may translate into better glycemic outcomes in the first year post-diagnosis.

    View details for DOI 10.1089/dia.2023.0405

    View details for PubMedID 37955644

  • Current Practices in Operationalizing and Addressing Racial Equity in the Provision of Type 1 Diabetes Care: Insights from the T1DX-QI Health Equity Advancement Lab. Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists Addala, A., Mungmode, A., Ospelt, E., Sanchez, J., Malik, F., Demeterco-Berggren, C., Butler, A., Edwards, C., Manukyan, M., Ochoa-Maya, M., Zupa, M., Ebekozien, O. 2023


    OBJECTIVE: Medical racism contributes to adverse health outcomes. T1DX-QI is a large population-based cohort engaged in data sharing and quality improvement to drive system changes in type 1 diabetes care. The annual T1DX-QI survey included questions to evaluate racial equity in diabetes care and practices to promote equity.METHODS: The annual T1DX-QI survey was administered to participating clinics fall 2022 and had a 93% response rate. There were 50 responses (pediatric-66%, adult-34%). Questions, in part, evaluated clinic resources and racial equity. Response data were aggregated, summarized and stratified by pediatric/adult institutions.RESULTS: Only 21% pediatric and 35% adult institutions felt all their team members can articulate how medical racism contributes to adverse diabetes outcomes. Pediatric institutions reported more strategies to address medical racism than adult (3.6 vs 3.1). Organizational strategies to decrease racial discrimination included employee trainings, DEI offices/committees, patient resources and hiring practices. Patient resources include interpreter services, transportation, insurance navigation, and housing and food assistance. Hiring practices included changing prior protocols, hiring from the community, and diversifying workforces. Majority of institutions have offered anti-racism training in the last year (pediatric-85%, adult-72%) and annually (pediatric-64%, adult-56%). Pediatric teams felt that their anti-racism training was effective more often (pediatric-60%, adult-45%) and more commonly were provided resources (pediatric-67%, adult-47%) to help address inequities.CONCLUSION: Despite increased offering in anti-racism training, insufficient institutional support and perceived subeffective training still represent obstacles especially in adult institutions. Sharing effective strategies to address medical racism will help institutions take steps to mitigate inequities.

    View details for DOI 10.1016/j.eprac.2023.10.001

    View details for PubMedID 37806550

  • Safe use of the ketogenic diet in an infant with microcephaly, epilepsy, and diabetes syndrome: a case report. BMC pediatrics Zegarra, W. A., Gallentine, W. B., Ruzhnikov, M. R., McAndrews, C. A., Gloyn, A. L., Addala, A. 2023; 23 (1): 453


    BACKGROUND: Microcephaly, epilepsy, and diabetes syndrome (MEDS) is a rare syndromic form of monogenic diabetes caused by bi-allelic loss of function mutations in IER3IP1. In vitro studies have shown that loss of IER31P leads to apoptosis in both neurons and pancreatic beta-cells. Simultaneous management of seizures and diabetes is challenging in patients with MEDS. We present the challenges and successes in the use of ketogenic diet in an infant with insulinopenic diabetes.CASE PRESENTATION: Our term female proband presented at 2 months of age with new onset multifocal seizures followed by the onset of infantile spasms (IS) at 4 months of age. An epilepsy gene panel identified bi-allelic variants, c.239T>G (p.Leu80*) and c.2T>A (initiator codon), in IER3IP1 that were subsequently shown to be inherited in trans. Following initiation of steroid therapy for IS, the patient developed clinically apparent insulin requiring diabetes. Her epilepsy was ultimately refractory to multiple antiseizure medications, thus the ketogenic diet (KD) was initiated. We were able to successfully titrate to a therapeutic KD ratio of 3:1 and maintain a ketotic state without diabetic ketoacidosis (DKA). With intercurrent illnesses, however, the patient had rapid decompensation and mild DKA due to delays in treatment, and for this reason, KD was discontinued after 5 months.CONCLUSIONS: We report two novel IER31P1 mutations in a patient with MEDS and the successful management of the cooccurring conditions of IS and insulinopenic diabetes with the KD. Our experience underscores the importance of careful monitoring during KD as our patient had DKA more easily when on the KD.

    View details for DOI 10.1186/s12887-023-04272-y

    View details for PubMedID 37689631

  • Multisite Quality Improvement Program Within the Project ECHO Diabetes Remote Network. Joint Commission journal on quality and patient safety Wang, C. J., Lewit, E. M., Clark, C. L., Lee, F. W., Maahs, D. M., Haller, M. J., Addala, A., Lal, R. A., Cuttriss, N., Baer, L. G., Figg, L. E., Anez-Zabala, C., Sheehan, E. P., Westen, S. C., Bernier, A. V., Donahoo, W. T., Walker, A. F. 2023


    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.

    View details for DOI 10.1016/j.jcjq.2023.08.001

    View details for PubMedID 37718146

  • The Promising Success of Project Extension for Community Healthcare Outcomes (ECHO) Diabetes: Case Series. JMIR diabetes Figg, L., Addala, A., Jain, I., Anez, C., Midney, P., DeChirico, C., Symanski, C., Fitzgerald, B. C., Colbert, K., Raymer, T., Stockton-Joreteg, C., Murphy, E., Collins, L., Bernstein, C., Hechavarria, M., Sheehan, E. P., Bernier, A., Westen, S. C., Hood, K. K., Zaharieva, D. P., Basina, M., Cuttriss, N., Filipp, S. L., Gurka, M. J., Walker, A. F., Maahs, D. M., Haller, M. J., Lal, R. A. 2023; 8: e46050


    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.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.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.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.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.

    View details for DOI 10.2196/46050

    View details for PubMedID 37535407

  • Sparking a Movement, Not a Moment: Framework and Outcomes From a Pediatrics Department-Wide Coalition to Advance Anti-Racism ACADEMIC PEDIATRICS Yemane, L., Ramirez, M., Guerin, A., Floyd, B., Okorie, C. A., Ling, W., Addala, A., Figg, L., Talley, E. M., Chamberlain, L. 2023; 23 (5): 886-892
  • An Overview of Diet and Physical Activity for Healthy Weight in Adolescents and Young Adults with Type 1 Diabetes: Lessons Learned from the ACT1ON Consortium. Nutrients Bishop, F. K., Addala, A., Corbin, K. D., Muntis, F. R., Pratley, R. E., Riddell, M. C., Mayer-Davis, E. J., Maahs, D. M., Zaharieva, D. P. 2023; 15 (11)


    The prevalence of overweight and obesity in young people with type 1 diabetes (T1D) now parallels that of the general population. Excess adiposity increases the risk of cardiovascular disease, which is already elevated up to 10-fold in T1D, underscoring a compelling need to address weight management as part of routine T1D care. Sustainable weight management requires both diet and physical activity (PA). Diet and PA approaches must be optimized towards the underlying metabolic and behavioral challenges unique to T1D to support glycemic control throughout the day. Diet strategies for people with T1D need to take into consideration glycemic management, metabolic status, clinical goals, personal preferences, and sociocultural considerations. A major barrier to weight management in this high-risk population is the challenge of integrating regular PA with day-to-day management of T1D. Specifically, exercise poses a substantial challenge due to the increased risk of hypoglycemia and/or hyperglycemia. Indeed, about two-thirds of individuals with T1D do not engage in the recommended amount of PA. Hypoglycemia presents a serious health risk, yet prevention and treatment often necessitates the consumption of additional calories, which may prohibit weight loss over time. Exercising safely is a concern and challenge with weight management and maintaining cardiometabolic health for individuals living with T1D and many healthcare professionals. Thus, a tremendous opportunity exists to improve exercise participation and cardiometabolic outcomes in this population. This article will review dietary strategies, the role of combined PA and diet for weight management, current resources for PA and glucose management, barriers to PA adherence in adults with T1D, as well as findings and lessons learned from the Advancing Care for Type 1 Diabetes and Obesity Network (ACT1ON).

    View details for DOI 10.3390/nu15112500

    View details for PubMedID 37299463

  • Expanding the use of patient-reported outcomes (PROs): Screening youth with type 1 diabetes from underrepresented populations. Journal of diabetes and its complications Addala, A., Wong, J. J., Penaranda, R. M., Hanes, S. J., Abujaradeh, H., Adams, R. N., Barley, R. C., Iturralde, E., Lanning, M. S., Tanenbaum, M. L., Naranjo, D., Hood, K. K. 2023; 37 (7): 108514


    Youth from lower socioeconomic status (SES) have suboptimal type 1 diabetes (T1D) outcomes. Patient reported outcomes (PROs) measure psychosocial states and are associated with T1D outcomes, however are understudied in low SES youth. We aimed to evaluate associations between PROs and public insurance status, a proxy for low SES.We analyzed survey data from 129 youth with T1D (age 15.7 ± 2.3 years, 33 % publicly insured) screened with PROMIS Global Health (PGH, measuring global health) and Patient Health Questionnaire (PHQ-9, measuring depressive symptoms) during diabetes appointments. Correlation and regression analyses evaluated differences in PGH and PHQ-9 by insurance status.For youth with public insurance, lower global health correlated with lower self-monitoring blood glucose (SMBG; r = 0.38,p = 0.033) and older age (r = -0.45,p = 0.005). In youth with private insurance, lower global health correlated with lower SMBG (r = 0.27,p = 0.018) and female sex (rho = 0.26,p = 0.015). For youth with private insurance, higher depressive symptoms correlated with higher body mass index (r = 0.22,p = 0.03) and fewer SMBG (r = -0.35,p = 0.04). In multivariate regression analyses, public insurance was inversely associated with global health (p = 0.027).PGH is a particularly salient PRO in youth with public insurance. Global health may be an important psychosocial factor to assess in youth with T1D from low SES backgrounds.

    View details for DOI 10.1016/j.jdiacomp.2023.108514

    View details for PubMedID 37263033

  • DiabetesWise: An innovative approach to promoting diabetes device awareness. Journal of diabetes Wong, J. J., Addala, A., Hanes, S. J., Krugman, S., Naranjo, D., Nelmes, S., Rose, K. J., Tanenbaum, M. L., Hood, K. K. 2023


    DiabetesWise is an unbranded, data-driven online resource that tailors device recommendations based on preferences and priorities of people with insulin-requiring diabetes. The objective of this study is to examine whether DiabetesWise increases uptake of diabetes devices, which are empirically supported to improve glycemic and psychosocial outcomes.The sample included 458 participants (Mage  = 37.1, SD = 9.73; 66% female; 81% type 1 diabetes) with insulin-requiring diabetes and minimal diabetes device use at enrollment. Participants used DiabetesWise and completed online surveys. Chi-square and t tests evaluated requests for a device prescription, receiving a prescription, and starting a new device at 1 and 3 months post use. Baseline predictors of these variables and past use of continuous glucose monitors (CGMs) and changes in diabetes distress post use were also examined.Within the first month of interacting with DiabetesWise 19% of participants asked for a prescription for a diabetes device. This rate rose to 31% in the first 3 months. These requests resulted in 16% of the sample starting a new device within the first 3 months. Whereas several factors were associated with prior CGM use, receiving a prescription, and starting a new device, more diabetes distress (t(343) = -3.13, p = .002) was the only factor associated with asking for a prescription. Diabetes distress decreased after interacting with DiabetesWise within 1 month (t(193) = 3.51, p < .001) and 3 months (t(180) = 5.23, p < .001).Within 3 months of interacting with DiabetesWise, one in three participants had requested a prescription for a new diabetes device and average distress levels were reduced, indicating benefit from this low-intensity online platform.

    View details for DOI 10.1111/1753-0407.13401

    View details for PubMedID 37139842

  • Perceived Knowledge and Confidence for Providing Youth-Specific Type 1 Diabetes Exercise Recommendations amongst Pediatric Diabetes Healthcare Professionals: An International, Cross-Sectional, Online Survey PEDIATRIC DIABETES Chinchilla, P., Dovc, K., Braune, K., Addala, A., Riddell, M. C., Dos Santos, T., Zaharieva, D. P. 2023; 2023
  • Real-World Diabetes Technology: Overcoming Barriers and Disparities. Diabetes technology & therapeutics Messer, L. H., Addala, A., Weinzimer, S. A. 2023; 25 (S1): S176-S190

    View details for DOI 10.1089/dia.2023.2511

    View details for PubMedID 36802191

  • Project ECHO Diabetes Cost Modeling to Support the Replication and Expansion of Tele-mentoring Programs in Non-research Settings. Diabetes therapy : research, treatment and education of diabetes and related disorders Lewit, E. M., Figg, L. E., Addala, A., Filipp, S. L., Lal, R., Gurka, M. J., Herndon, J. B., Haller, M. J., Maahs, D. M., Walker, A. F. 2023


    Project ECHO Diabetes is a tele-education learning model for primary care providers (PCPs) seeking to improve care for patients with diabetes from marginalized communities. Project ECHO Diabetes utilized expert "hub" teams comprising endocrinologists, dieticians, nurses, psychologists, and social workers and "spokes" consisting of PCPs and their patients with diabetes. This Project ECHO Diabetes model provided diabetes support coaches to provide additional support to patients. We sought to estimate the costs of operating a Project ECHO Diabetes hub, inclusive of diabetes support coach costs.Data from Project ECHO Diabetes from June 2021 to June 2022 and wages from national databases were used to estimate hub and diabetes support coach costs to operate a 6-month, 24-session Project ECHO Diabetes program at hubs (University of Florida and Stanford University) and spokes (PCP clinic sites in Florida and California).Hub costs for delivering a 6-month Project ECHO Diabetes program to five spoke clinics were $96,873. Personnel costs were the principal driver. Mean cost was $19,673 per spoke clinic and $11.37 per spoke clinic patient. Diabetes support coach costs were estimated per spoke clinic and considered scalable in that they would increase proportionately with the number of spoke clinics in a Project ECHO Diabetes cohort. Mean diabetes support coach costs were $6,506 per spoke clinic and $3.72 per patient. Total program costs per hub were $129,404. Mean cost per clinic was $25,881. Mean cost per patient was $15.03.Herein, we document real-world costs to operate a Project ECHO Diabetes hub and diabetes support coaches. Future analysis of Project ECHO Diabetes will include estimates of spoke participation costs and changes in health care costs and savings. As state agencies, insurers, and philanthropies consider the replication of Project ECHO Diabetes, this analysis provides important initial information regarding primary operating costs.

    View details for DOI 10.1007/s13300-022-01364-3

    View details for PubMedID 36680682

  • Associations of disordered eating with the intestinal microbiota and short-chain fatty acids among young adults with type 1 diabetes. Nutrition, metabolism, and cardiovascular diseases : NMCD Igudesman, D., Crandell, J., Corbin, K. D., Zaharieva, D. P., Addala, A., Thomas, J. M., Bulik, C. M., Pence, B. W., Pratley, R. E., Kosorok, M. R., Maahs, D. M., Carroll, I. M., Mayer-Davis, E. J. 2022


    Disordered eating (DE) in type 1 diabetes (T1D) includes insulin restriction for weight loss with serious complications. Gut microbiota-derived short chain fatty acids (SCFA) may benefit host metabolism but are reduced in T1D. We evaluated the hypothesis that DE and insulin restriction were associated with reduced SCFA-producing gut microbes, SCFA, and intestinal microbial diversity in adults with T1D.We collected stool samples at four timepoints in a hypothesis-generating gut microbiome pilot study ancillary to a weight management pilot in young adults with T1D. 16S ribosomal RNA gene sequencing measured the normalized abundance of SCFA-producing intestinal microbes. Gas-chromatography mass-spectrometry measured SCFA (total, acetate, butyrate, and propionate). The Diabetes Eating Problem Survey-Revised (DEPS-R) assessed DE and insulin restriction. Covariate-adjusted and Bonferroni-corrected generalized estimating equations modeled the associations. COVID-19 interrupted data collection, so models were repeated restricted to pre-COVID-19 data. Data were available for 45 participants at 109 visits, which included 42 participants at 65 visits pre-COVID-19. Participants reported restricting insulin "At least sometimes" at 53.3% of visits. Pre-COVID-19, each 5-point DEPS-R increase was associated with a -0.34 (95% CI -0.56, -0.13, p = 0.07) lower normalized abundance of genus Anaerostipes; and the normalized abundance of Lachnospira genus was -0.94 (95% CI -1.5, -0.42), p = 0.02 lower when insulin restriction was reported "At least sometimes" compared to "Rarely or Never".DE and insulin restriction were associated with a reduced abundance of SCFA-producing gut microbes pre-COVID-19. Additional studies are needed to confirm these associations to inform microbiota-based therapies in T1D.

    View details for DOI 10.1016/j.numecd.2022.11.017

    View details for PubMedID 36586772

  • A model to design financially sustainable algorithm-enabled remote patient monitoring for pediatric type 1 diabetes care. Frontiers in endocrinology Dupenloup, P., Pei, R. L., Chang, A., Gao, M. Z., Prahalad, P., Johari, R., Schulman, K., Addala, A., Zaharieva, D. P., Maahs, D. M., Scheinker, D. 2022; 13: 1021982


    Population-level algorithm-enabled remote patient monitoring (RPM) based on continuous glucose monitor (CGM) data review has been shown to improve clinical outcomes in diabetes patients, especially children. However, existing reimbursement models are geared towards the direct provision of clinic care, not population health management. We developed a financial model to assist pediatric type 1 diabetes (T1D) clinics design financially sustainable RPM programs based on algorithm-enabled review of CGM data.Data were gathered from a weekly RPM program for 302 pediatric patients with T1D at Lucile Packard Children's Hospital. We created a customizable financial model to calculate the yearly marginal costs and revenues of providing diabetes education. We consider a baseline or status quo scenario and compare it to two different care delivery scenarios, in which routine appointments are supplemented with algorithm-enabled, flexible, message-based contacts delivered according to patient need. We use the model to estimate the minimum reimbursement rate needed for telemedicine contacts to maintain revenue-neutrality and not suffer an adverse impact to the bottom line.The financial model estimates that in both scenarios, an average reimbursement rate of roughly $10.00 USD per telehealth interaction would be sufficient to maintain revenue-neutrality. Algorithm-enabled RPM could potentially be billed for using existing RPM CPT codes and lead to margin expansion.We designed a model which evaluates the financial impact of adopting algorithm-enabled RPM in a pediatric endocrinology clinic serving T1D patients. This model establishes a clear threshold reimbursement value for maintaining revenue-neutrality, as well as an estimate of potential RPM reimbursement revenue which could be billed for. It may serve as a useful financial-planning tool for a pediatric T1D clinic seeking to leverage algorithm-enabled RPM to provide flexible, more timely interventions to its patients.

    View details for DOI 10.3389/fendo.2022.1021982

    View details for PubMedID 36440201

    View details for PubMedCentralID PMC9691757

  • The Impact of Telehealth Adoption During COVID-19 Pandemic on Patterns of Pediatric Subspecialty Care Utilization ACADEMIC PEDIATRICS Cahan, E. M., Maturi, J., Bailey, P., Fernandes, S., Addala, A., Kibrom, S., Krissberg, J. R., Smith, S. M., Shah, S., Wang, E., Saynina, O., Wise, P. H., Chamberlain, L. J. 2022; 22 (8): 1375-1383
  • Weight Management in Young Adults with Type 1 Diabetes: The Advancing Care for Type 1 Diabetes and Obesity Network Sequential Multiple Assignment Randomized Trial Pilot Results. Diabetes, obesity & metabolism Igudesman, D., Crandell, J., Corbin, K. D., Zaharieva, D. P., Addala, A., Thomas, J. M., Casu, A., Kirkman, M. S., Pokaprakarn, T., Riddell, M. C., Burger, K., Pratley, R. E., Kosorok, M. R., Maahs, D. M., Mayer-Davis, E. J., ACT1ON Study Group 2022


    AIMS: Co-management of weight and glycemia is critical yet challenging in type 1 diabetes (T1D). We evaluated the effect of a hypocaloric low carbohydrate, hypocaloric moderate low fat, and Mediterranean diet without calorie restriction on weight and glycemia in young adults with T1D and overweight or obesity.MATERIALS AND METHODS: We implemented a nine-month Sequential, Multiple Assignment, Randomized Trial pilot among adults aged 19-30years with T1D for ≥1 year and BMI 27-39.9 kg/m2 . Re-randomization occurred at 3- and 6-months if the assigned diet was not acceptable or not effective. We report results from the initial three-month diet period and rerandomization statistics prior to shutdowns due to COVID-19 for primary (weight, hemoglobin A1c [HbA1c], percent of time below range [%TBR] <70 mg/dL) and secondary outcomes (body fat percentage [BFP], percent of time in range [70-180 mg/dL], and %TBR <54 mg/dL). Models adjusted for design, demographic, and clinical covariates tested changes in outcomes and diet differences.RESULTS: Adjusted weight and HbA1c (n=38) changed by -2.7 kg (95%CI -3.8, -1.5, p<0.0001) and -0.91 percentage points (95%CI -1.5, -0.30, p=0.005), respectively, while adjusted BFP remained stable, on average (p=0.21). Hypoglycemia indices remained unchanged, on average, following adjustment (n=28, p>0.05). Variability in all outcomes, including weight change, was considerable (57.9% were re-randomized primarily due to loss of <2% body weight). No outcomes varied by diet.CONCLUSIONS: Three months of a diet, irrespective of macronutrient distribution or caloric restriction, resulted in weight loss while improving HbA1c levels without increasing hypoglycemia in adults with T1D. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1111/dom.14911

    View details for PubMedID 36314293

  • An Evaluation of Point-of-Care HbA1c, HbA1c Home Kits, and Glucose Management Indicator: Potential Solutions for Telehealth Glycemic Assessments. Diabetology Zaharieva, D. P., Addala, A., Prahalad, P., Leverenz, B., Arrizon-Ruiz, N., Ding, V. Y., Desai, M., Karger, A. B., Maahs, D. M. 2022; 3 (3): 494-501


    During the COVID-19 pandemic, fewer in-person clinic visits resulted in fewer point-of-care (POC) HbA1c measurements. In this sub-study, we assessed the performance of alternative glycemic measures that can be obtained remotely, such as HbA1c home kits and Glucose Management Indicator (GMI) values from Dexcom Clarity. Home kit HbA1c (n = 99), GMI, (n = 88), and POC HbA1c (n = 32) were collected from youth with T1D (age 9.7 ± 4.6 years). Bland-Altman analyses and Lin's concordance correlation coefficient (rhoc) were used to characterize the agreement between paired HbA1c measures. Both the HbA1c home kit and GMI showed a slight positive bias (mean difference 0.18% and 0.34%, respectively) and strong concordance with POC HbA1c (rhoc = 0.982 [0.965, 0.991] and 0.823 [0.686, 0.904], respectively). GMI showed a slight positive bias (mean difference 0.28%) and fair concordance (rhoc = 0.750 [0.658, 0.820]) to the HbA1c home kit. In conclusion, the strong concordance of GMI and home kits to POC A1c measures suggest their utility in telehealth visits assessments. Although these are not candidates for replacement, these measures can facilitate telehealth visits, particularly in the context of other POC HbA1c measurements from an individual.

    View details for DOI 10.3390/diabetology3030037

    View details for PubMedID 37163187

  • Relationship Between Moderate-to-Vigorous Physical Activity and Glycemia Among Young Adults with Type 1 Diabetes and Overweight or Obesity: Results from the Advancing Care for Type 1 Diabetes and Obesity Network (ACT1ON) Study. Diabetes technology & therapeutics Muntis, F. R., Igudesman, D., Cristello Sarteau, A., Thomas, J., Arrizon-Ruiz, N., Hooper, J., Addala, A., Crandell, J. L., Riddell, M. C., Maahs, D. M., Pratley, R. E., Corbin, K., Mayer-Davis, E. J., Zaharieva, D. P. 2022


    AIMS: Using data from the ACT1ON study, we conducted secondary analyses to assess the relationship between minutes of moderate-to-vigorous physical activity (MVPA) and glycemia in adults with type 1 diabetes (T1D) and overweight or obesity.MATERIALS AND METHODS: Participants (n=66) with T1D provided measures of glycemia (HbA1c, percent of time below range [TBR, <70mg/dL], time-in-range [TIR, 70-180mg/dL], time above range [TAR, >180mg/dL]) and self-reported physical activity (Global Physical Activity Questionnaire (GPAQ), Previous Day Physical Activity Recalls (PDPAR)) at baseline, 3-, 6-, & 9-months post-intervention. Wearable activity data was available for a subset of participants (n=27). Associations were estimated using mixed effects regression models adjusted for design, demographic, clinical, and dietary covariates.RESULTS: Among young adults aged 19-30 with a baseline HbA1c of 7.9 ± 1.4% and BMI of 30.3 (IQR 27.9, 33.8), greater habitual weekly MVPA minutes were associated with higher HbA1c via the GPAQ (p<0.01) and wearable activity data (p=0.01). We did not observe a significant association between habitual MVPA and any continuous glucose monitoring metrics. Using PDPAR data, however, we observed that greater daily MVPA minutes were associated with more TAR (p<0.01) and reduced TIR (p<0.01) on the day following reported physical activity.CONCLUSIONS: Among young adults with T1D and overweight or obesity, increased MVPA was associated with worsened glycemia. As physical activity is vital to cardiovascular health and weight management, additional research is needed to determine how to best support young adults with T1D and overweight or obesity in their efforts to increase physical activity.

    View details for DOI 10.1089/dia.2022.0253

    View details for PubMedID 35984327

  • "Much more convenient, just as effective:" Experiences of starting continuous glucose monitoring remotely following Type 1 diabetes diagnosis. Diabetic medicine : a journal of the British Diabetic Association Tanenbaum, M. L., Zaharieva, D. P., Addala, A., Prahalad, P., Hooper, J. A., Leverenz, B., Cortes, A. L., Arrizon-Ruiz, N., Pang, E., Bishop, F., Maahs, D. M. 2022: e14923


    Initiating continuous glucose monitoring (CGM) shortly after Type 1 diabetes diagnosis has glycemic and quality of life benefits for youth with Type 1 diabetes and their families. The SARS-CoV-2 pandemic led to a rapid shift to virtual delivery of CGM initiation visits. We aimed to understand parents' experiences receiving virtual care to initiate CGM within 30 days of diagnosis.We held focus groups and interviews using a semi-structured interview guide with parents of youth who initiated CGM over telehealth within 30 days of diagnosis during the SARS-CoV-2 pandemic. Questions aimed to explore experiences of starting CGM virtually. Groups and interviews were audio-recorded, transcribed, and analyzed using thematic analysis.Participants were 16 English-speaking parents (age 43±6 years; 63% female) of 15 youth (age 9±4 years; 47% female; 47% non-Hispanic White, 20% Hispanic, 13% Asian, 7% Black, 13% other). They described multiple benefits of the virtual visit including convenient access to high-quality care; integrating Type 1 diabetes care into daily life; and being in the comfort of home. A minority experienced challenges with virtual care delivery; most preferred the virtual format. Participants expressed that clinics should offer a choice of virtual or in-person to families initiating CGM in the future.Most parents appreciated receiving CGM initiation education via telehealth and felt it should be an option offered to all families. Further efforts can continue to enhance CGM initiation teaching virtually to address identified barriers.

    View details for DOI 10.1111/dme.14923

    View details for PubMedID 35899591

  • Design of the advancing care for type 1 diabetes and obesity network energy metabolism and sequential multiple assignment randomized trial nutrition pilot studies: An integrated approach to develop weight management solutions for individuals with type 1 diabetes. Contemporary clinical trials Corbin, K. D., Igudesman, D., Addala, A., Casu, A., Crandell, J., Kosorok, M. R., Maahs, D. M., Pokaprakarn, T., Pratley, R. E., Souris, K. J., Thomas, J., Zaharieva, D. P., Mayer-Davis, E. 2022: 106765


    Young adults with type 1 diabetes (T1D) often have difficulty co-managing weight and glycemia. The prevalence of overweight and obesity among individuals with T1D now parallels that of the general population and contributes to dyslipidemia, insulin resistance, and risk for cardiovascular disease. There is a compelling need to develop a program of research designed to optimize two key outcomes-weight management and glycemia-and to address the underlying metabolic processes and behavioral challenges unique to people with T1D. For an intervention addressing these dual outcomes to be effective, it must be appropriate to the unique metabolic phenotype of T1D, and to biological and behavioral responses to glycemia (including hypoglycemia) that relate to weight management. The intervention must also be safe, feasible, and accepted by young adults with T1D. In 2015, we established a consortium called ACT1ON: Advancing Care for Type 1 Diabetes and Obesity Network, a transdisciplinary team of scientists at multiple institutions. The ACT1ON consortium designed a multi-phase study which, in parallel, evaluated the mechanistic aspects of the unique metabolism and energy requirements of individuals with T1D, alongside a rigorous adaptive behavioral intervention to simultaneously facilitate weight management while optimizing glycemia. This manuscript describes the design of our integrative study-comprised of an inpatient mechanistic phase and an outpatient behavioral phase-to generate metabolic, behavioral, feasibility, and acceptability data to support a future, fully powered sequential, multiple assignment, randomized trial to evaluate the best approaches to prevent and treat obesity while co-managing glycemia in people with T1D. identifiers: NCT03651622 and NCT03379792. The present study references can be found here: Submission Category: "Study Design, Statistical Design, Study Protocols".

    View details for DOI 10.1016/j.cct.2022.106765

    View details for PubMedID 35460915

  • The Impact of Telehealth Adoption During COVID-19 Pandemic on Patterns of Pediatric Subspecialty Care Utilization. Academic pediatrics Cahan, E. M., Maturi, J., Bailey, P., Fernandes, S., Addala, A., Kibrom, S., Krissberg, J. R., Smith, S. M., Shah, S., Wang, E., Saynina, O., Wise, P. H., Chamberlain, L. J. 2022


    OBJECTIVE: The COVID-19 pandemic prompted health systems to rapidly adopt telehealth for clinical care. We examined the impact of demography, subspecialty characteristics, and broadband availability on the utilization of telehealth in pediatric populations before and after the early period of the COVID-19 pandemic.METHODS: Outpatients scheduled for subspecialty visits at sites affiliated with a single quaternary academic medical center between March - June 2019 and March - June 2020 were included. The contribution of demographic, socioeconomic, and broadband availability to visit completion and telehealth utilization were examined in multivariable regression analyses.RESULTS: Among visits scheduled in 2020 compared to 2019, in-person visits fell from 23,318 to 11,209, while telehealth visits increased from 150 to 7,675. Visits among established patients fell by 15% and new patients by 36% (p<.0001). Multivariable analysis revealed that completed visits were reduced for Hispanic patients and those with reduced broadband; high income, private non-HMO insurance, and those requesting an interpreter were more likely to complete visits. Of those with visits scheduled in 2020, established patients, those with reduced broadband, and patients older than 1 year were more likely to complete TH appointments. Cardiology, oncology, and pulmonology patients were less likely to complete scheduled TH appointments.CONCLUSIONS: Following COVID-19 onset, outpatient pediatric subspecialty visits shifted rapidly to telehealth. However, the impact of this shift on social disparities in outpatient utilization was mixed with variation among subspecialties. A growing reliance on telehealth will necessitate insights from other healthcare settings serving populations of diverse social and technological character.

    View details for DOI 10.1016/j.acap.2022.03.010

    View details for PubMedID 35318159

  • Mindfulness, disordered eating, and impulsivity in relation to glycemia among adolescents with type 1 diabetes and suboptimal glycemia from the Flexible Lifestyles Empowering Change (FLEX) Intervention Trial. Pediatric diabetes Irwin, A., Igudesman, D., Crandell, J., Kichler, J. C., Kahkoska, A. R., Burger, K., Zaharieva, D. P., Addala, A., Mayer-Davis, E. J. 2022


    OBJECTIVE: To assess the relationship between mindfulness and glycemia among adolescents with type 1 diabetes (T1D) with suboptimal glycemia, and evaluate the potential mediation by ingestive behaviors, including disordered eating, and impulsivity.METHODS: We used linear mixed models for hemoglobin A1c (HbA1c) and linear regression for continuous glucose monitoring (CGM) to study the relationship of mindfulness [Child and Adolescent Mindfulness Measure (CAMM)] and glycemia in adolescents with T1D from the 18-month Flexible Lifestyles Empowering Change (FLEX) trial. We tested for mediation of the mindfulness-glycemia relationship by ingestive behaviors, including disordered eating (Diabetes Eating Problem Survey - Revised), restrained eating, and emotional eating (Dutch Eating Behavior Questionnaire); and impulsivity (total, attentional, and motor, Barrett Impulsiveness Scale).RESULTS: At baseline, participants (n=152) had a mean age of 14.9 ±1.1years and HbA1c of 9.4 ±1.2% [79±13mmol/mol]. The majority of adolescents were non-Hispanic white (83.6%), 50.7% were female, and 73.0% used insulin pumps. From adjusted mixed models, a 5-point increase in mindfulness scores was associated with a -0.19% (95%CI -0.29, -0.08, p=0.0006) reduction in HbA1c. We did not find statistically significant associations between mindfulness and CGM metrics. Mediation of the relationship between mindfulness and HbA1c by ingestive behaviors and impulsivity was not found to be statistically significant.CONCLUSIONS: Among adolescents with T1D and suboptimal glycemia, increased mindfulness was associated with lower HbA1c levels. Future studies may consider mindfulness-based interventions as a component of treatment for improving glycemia among adolescents with T1D, though more data are needed to assess feasibility and efficacy. Words: 250/250 This article is protected by copyright. All rights reserved.

    View details for DOI 10.1111/pedi.13334

    View details for PubMedID 35297136

  • Diabetes Technology and Therapy in the Pediatric Age Group. Diabetes technology & therapeutics Maahs, D. M., Addala, A., Shalitin, S. 2022; 24 (S1): S107-S128

    View details for DOI 10.1089/dia.2022.2507

    View details for PubMedID 35475702

  • Current and Novel Strategies to Reduce Fear of Hypoglycemia as a Barrier to Physical Activity in Adults and Youth With Type 1 Diabetes. Canadian journal of diabetes Zaharieva, D. P., Addala, A. 2022; 46 (1): 1-2

    View details for DOI 10.1016/j.jcjd.2021.12.004

    View details for PubMedID 35144756

  • Tele-education model for primary care providers to advance diabetes equity: Findings from Project ECHO Diabetes. Frontiers in endocrinology Addala, A., Filipp, S. L., Figg, L. E., Anez-Zabala, C., Lal, R. A., Gurka, M. J., Haller, M. J., Maahs, D. M., Walker, A. F., Project ECHO Diabetes Research Team, Haller, M., Sheehan, E., Bernier, A., Westen, S., Stahmer, H., Donahoo, W. T., Roque, X., Malden, G., Hechavarria, M., Maahs, D., Lal, R., Addala, A., Figg, L., Yabut, K., Alramahi, N., Cortes, A., Zaharieva, D., Basina, M., Judge, K., Wilke, L., Hood, K., Wong, J., Wang, J., Bhatia, S., Lewit, E. 2022; 13: 1066521


    Introduction: In the US, many individuals with diabetes do not have consistent access to endocrinologists and therefore rely on primary care providers (PCPs) for their diabetes management. Project ECHO (Extension for Community Healthcare Outcomes) Diabetes, a tele-education model, was developed to empower PCPs to independently manage diabetes, including education on diabetes technology initiation and use, to bridge disparities in diabetes.Methods: PCPs (n=116) who participated in Project ECHO Diabetes and completed pre- and post-intervention surveys were included in this analysis. The survey was administered in California and Florida to participating PCPs via REDCap and paper surveys. This survey aimed to evaluate practice demographics, protocols with adult and pediatric T1D management, challenges, resources, and provider knowledge and confidence in diabetes management. Differences and statistical significance in pre- and post-intervention responses were evaluated via McNemar's tests.Results: PCPs reported improvement in all domains of diabetes education and management. From baseline, PCPs reported improvement in their confidence to serve as the T1D provider for their community (pre vs post: 43.8% vs 68.8%, p=0.005), manage insulin therapy (pre vs post: 62.8% vs 84.3%, p=0.002), and identify symptoms of diabetes distress (pre vs post: 62.8% vs 84.3%, p=0.002) post-intervention. Compared to pre-intervention, providers reported significant improvement in their confidence in all aspects of diabetes technology including prescribing technology (41.2% vs 68.6%, p=0.001), managing insulin pumps (41.2% vs 68.6%, p=0.001) and hybrid closed loop (10.2% vs 26.5%, p=0.033), and interpreting sensor data (41.2% vs 68.6%, p=0.001) post-intervention.Discussion: PCPs who participated in Project ECHO Diabetes reported increased confidence in diabetes management, with notable improvement in their ability to prescribe, manage, and troubleshoot diabetes technology. These data support the use of tele-education of PCPs to increase confidence in diabetes technology management as a feasible strategy to advance equity in diabetes management and outcomes.

    View details for DOI 10.3389/fendo.2022.1066521

    View details for PubMedID 36589850

  • Using Peer Power to Reduce Health Disparities: Implementation of a Diabetes Support Coach Program in Federally Qualified Health Centers. Diabetes spectrum : a publication of the American Diabetes Association Walker, A. F., Addala, A., Sheehan, E., Lal, R., Haller, M., Cuttriss, N., Filipp, S., Baer, L., Gurka, M., Bernier, A., Figg, L., Westen, S., Hood, K., Anez-Zabala, C., Frank, E., Roque, X., Maizel, J., Maahs, D. 2022; 35 (3): 295-303


    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.

    View details for DOI 10.2337/dsi22-0004

    View details for PubMedID 36082018

  • Teamwork, Targets, Technology, and Tight Control in Newly Diagnosed Type 1 Diabetes: Pilot 4T Study. The Journal of clinical endocrinology and metabolism Prahalad, P., Ding, V. Y., Zaharieva, D. P., Addala, A., Johari, R., Scheinker, D., Desai, M., Hood, K., Maahs, D. M. 2021


    CONTEXT: Youth with type 1 diabetes (T1D) do not meet hemoglobin A1c (HbA1c) targets.OBJECTIVE: To assess HbA1c outcomes in children with new onset T1D enrolled in the Teamwork, Targets, Technology and Tight Control (4T) Study.METHOD: HbA1c levels were compared between the 4T and Historical cohorts. HbA1c differences between cohorts were estimated using locally estimated scatter plot smoothing (LOESS). The change from nadir HbA1c (month 4) to 12 months post-diagnosis was estimated by cohort using a piecewise mixed effects regression model accounting for age at diagnosis, sex, ethnicity, and insurance type.SETTING AND PARTICIPANTS: We recruited 135 youth with newly diagnosed T1D at Stanford Children's Health.INTERVENTION: Starting July 2018, all youth within the first month of T1D diagnosis were offered continuous glucose monitoring (CGM) initiation and remote CGM data review was added in March 2019.MAIN OUTCOME MEASURE: HbA1c.RESULTS: HbA1c at 6, 9, and 12 months post-diagnosis was lower in the 4T cohort than in the Historic cohort (-0.54%, -0.52%, and -0.58%, respectively). Within the 4T cohort, HbA1c at 6, 9, and 12 months post-diagnosis was lower in those patients with Remote Monitoring than those without (-0.14%, -0.18%, -0.14%, respectively). Multivariable regression analysis showed that the 4T cohort experienced a significantly lower increase in HbA1c between months 4 and 12 (p < 0.001).CONCLUSIONS: A technology-enabled team-based approach to intensified new onset education involving target setting, CGM initiation, and remote data review significantly decreased HbA1c in youth with T1D 12 months post-diagnosis.

    View details for DOI 10.1210/clinem/dgab859

    View details for PubMedID 34850024

  • Heterogeneity in the Impact of the COVID-19 Pandemic on Disparities in Pediatric Endocrine Care Addala, A., Shah, S., Saynina, O., Wise, P., Chamberlain, L. KARGER. 2021: 51-52
  • Global Well-Being Is Associated With A1C and Frequency of Self-Monitoring of Blood Glucose in Predominately Latinx Youth and Young Adults With Type 1 Diabetes. Diabetes spectrum : a publication of the American Diabetes Association Addala, A., Chan, R. Y., Vargas, J., Weigensberg, M. J. 2021; 34 (2): 202-208

    View details for DOI 10.2337/ds20-0041

    View details for PubMedID 34149262

  • Changes to Care Delivery at Nine International Pediatric Diabetes Clinics in Response to the COVID-19 Global Pandemic. Pediatric diabetes Cristello Sarteau, A. n., Souris, K. J., Wang, J. n., Ramadan, A. A., Addala, A. n., Bowlby, D. n., Corathers, S. n., Forsander, G. n., King, B. n., Law, J. R., Liu, W. n., Malik, F. n., Pihoker, C. n., Seid, M. n., Smart, C. n., Sundberg, F. n., Tandon, N. n., Yao, M. n., Headley, T. n., Mayer-Davis, E. n. 2021


    Pediatric diabetes clinics around the world rapidly adapted care in response to COVID-19. We explored provider perceptions of care delivery adaptations and challenges for providers and patients across nine international pediatric diabetes clinics.Providers in a quality improvement collaborative completed a questionnaire about clinic adaptations, including roles, care delivery methods, and provider and patient concerns and challenges. We employed a rapid analysis (RA) to identify main themes.Providers described adaptations within multiple domains of care delivery, including provider roles and workload, clinical encounter and team meeting format, care delivery platforms, self-management technology education, and patient-provider data sharing. Providers reported concerns about potential negative impacts on patients from COVID-19 and the clinical adaptations it required, including fears related to telemedicine efficacy, blood glucose and insulin pump/pen data sharing, and delayed care-seeking. Particular concern was expressed about already vulnerable patients. Simultaneously, providers reported 'silver linings' of adaptations that they perceived as having potential to inform care and self-management recommendations going forward, including time-saving clinic processes, telemedicine, lifestyle changes compelled by COVID-19, and improvements to family and clinic staff literacy around data sharing.Providers across diverse clinical settings reported care delivery adaptations in response to COVID-19 --particularly telemedicine processes-- created challenges and opportunities to improve care quality and patient health. To develop quality care during COVID-19, providers emphasized the importance of generating evidence about which in-person or telemedicine processes were most beneficial for specific care scenarios, and incorporating the unique care needs of the most vulnerable patients. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1111/pedi.13180

    View details for PubMedID 33470020

  • Barriers to Technology Use and Endocrinology Care for Underserved Communities With Type 1 Diabetes. Diabetes care Walker, A. F., Hood, K. K., Gurka, M. J., Filipp, S. L., Anez-Zabala, C. n., Cuttriss, N. n., Haller, M. J., Roque, X. n., Naranjo, D. n., Aulisio, G. n., Addala, A. n., Konopack, J. n., Westen, S. n., Yabut, K. n., Mercado, E. n., Look, S. n., Fitzgerald, B. n., Maizel, J. n., Maahs, D. M. 2021


    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.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).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).These findings provide novel insights into the experiences of vulnerable communities and demonstrate the need for multilevel interventions aimed at offsetting disparities in diabetes.

    View details for DOI 10.2337/dc20-2753

    View details for PubMedID 34001535

  • Clinically serious hypoglycemia is rare and not associated with time-in-range in youth with new-onset type 1 diabetes. The Journal of clinical endocrinology and metabolism Addala, A., Zaharieva, D. P., Gu, A. J., Prahalad, P., Scheinker, D., Buckingham, B., Hood, K. K., Maahs, D. M. 2021


    Early initiation of continuous glucose monitoring (CGM) is advocated for youth with type 1 diabetes (T1D). Data to guide CGM use on time-in-range (TIR), hypoglycemia, and the role of partial clinical remission (PCR) are limited. Our aims were to assess whether: 1) an association between increased TIR and hypoglycemia exists, and 2) how time in hypoglycemia varies by PCR status.We analyzed 80 youth who were started on CGM shortly after T1D diagnosis and were followed for up to 1-year post-diagnosis. TIR and hypoglycemia rates were determined by CGM data and retrospectively analyzed. PCR was defined as (visit-HbA1c)+(4*units/kg/day) <9.Youth were started on CGM 8.0 (IQR 6.0-13.0) days post-diagnosis. Time spent <70mg/dL remained low despite changes in TIR (highest TIR 74.6±16.7%, 2.4±2.4% hypoglycemia at 1 month post-diagnosis; lowest TIR 61.3±20.3%, 2.1±2.7% hypoglycemia at 12 months post-diagnosis). No events of severe hypoglycemia occurred. Hypoglycemia was rare and there was minimal difference for PCR versus non-PCR youth (54-70mg/dL: 1.8% vs 1.2%, p=0.04; <54mg/dL: 0.3% vs 0.3%, p=0.55). Approximately 50% of the time spent in hypoglycemia was in the 65-70mg/dL range.As TIR gradually decreased over 12 months post-diagnosis, hypoglycemia was limited with no episodes of severe hypoglycemia. Hypoglycemia rates did not vary in a clinically meaningful manner by PCR status. With CGM being started earlier, consideration needs to be given to modifying CGM hypoglycemia education, including alarm settings. These data support a trial in the year post-diagnosis to determine alarm thresholds for youth who wear CGM.

    View details for DOI 10.1210/clinem/dgab522

    View details for PubMedID 34265059

  • "I was ready for it at the beginning": Parent experiences with early introduction of continuous glucose monitoring following their child's Type 1 diabetes diagnosis. Diabetic medicine : a journal of the British Diabetic Association Tanenbaum, M. L., Zaharieva, D. P., Addala, A. n., Ngo, J. n., Prahalad, P. n., Leverenz, B. n., New, C. n., Maahs, D. M., Hood, K. K. 2021: e14567


    To capture the experience of parents of youth with recent onset Type 1 diabetes who initiated use of continuous glucose monitoring (CGM) technology soon after diagnosis, which is a new practice.Focus groups and individual interviews were conducted with parents of youth with Type 1 diabetes who had early initiation of CGM as part of a new clinical protocol. Interviewers used a semi-structured interview guide to elicit feedback and experiences with starting CGM within 30 days of diagnosis, and the benefits and barriers they experienced when adjusting to this technology. Groups and interviews were audio-recorded, transcribed, and analyzed using content analysis.Participants were 16 parents (age 44.13±8.43 years; 75% female; 56.25% non-Hispanic White) of youth (age 12.38±4.15 years; 50% female; 50% non-Hispanic White; diabetes duration 10.35±3.89 months) who initiated CGM 11.31±7.33 days after diabetes diagnosis. Overall, parents reported high levels of satisfaction with starting CGM within a month of diagnosis and described a high level of reliance on the technology to help manage their child's diabetes. All participants recommended early CGM initiation for future families and were committed to continue using the technology for the foreseeable future, provided that insurance covered it.Parents experienced CGM initiation shortly after their child's Type 1 diabetes diagnosis as a highly beneficial and essential part of adjusting to living with diabetes.

    View details for DOI 10.1111/dme.14567

    View details for PubMedID 33772862

  • Weight Management in Youth with Type 1 Diabetes and Obesity: Challenges and Possible Solutions. Current obesity reports Zaharieva, D. P., Addala, A., Simmons, K. M., Maahs, D. M. 2020


    PURPOSE OF REVIEW: This review highlights challenges associated with weight management in children and adolescents with type 1 diabetes (T1D). Our purpose is to propose potential solutions to improve weight outcomes in youth with T1D.RECENT FINDINGS: A common barrier to weight management in T1D is reluctance to engage in exercise for fear of hypoglycemia. Healthcare practitioners generally provide limited guidance for insulin dosing and carbohydrate modifications to maintain stable glycemia during exercise. Adherence to dietary guidelines is associated with improved glycemia; however, youth struggle to meet recommendations. When psychosocial factors are addressed in combination with glucose trends, this often leads to successful T1D management. Newer medications also hold promise to potentially aid in glycemia and weight management, but further research is necessary. Properly addressing physical activity, nutrition, pharmacotherapy, and psychosocial factors while emphasizing weight management may reduce the likelihood of obesity development and its perpetuation in this population.

    View details for DOI 10.1007/s13679-020-00411-z

    View details for PubMedID 33108635

  • Clinically Significant Hypoglycemia Is Rare in Youth with T1D during Partial Clinical Remission Addala, A., Gu, A., Zaharieva, D., Prahalad, P., Buckingham, B. A., Scheinker, D., Maahs, D. M. AMER DIABETES ASSOC. 2020
  • The Association between Time-in-Range, Mean Glucose, and Incidence of Hypoglycemia in Youth with Newly Diagnosed T1D Gu, A., Prahalad, P., Maahs, D. M., Addala, A., Scheinker, D. AMER DIABETES ASSOC. 2020
  • Early Introduction of Continuous Glucose Monitoring Is Well Accepted by Youth and Parents Addala, A., Hanes, S., Zaharieva, D., New, C., Prahalad, P., Maahs, D. M., Hood, K. K., Tanenbaum, M. L. AMER DIABETES ASSOC. 2020
  • Newly Diagnosed Pediatric Patients with Type 1 Diabetes Show Steady Decline in Glucose Time-in-Range (TIR) over 1 Year: Pilot Study Zaharieva, D., Prahalad, P., Addala, A., Scheinker, D., Desai, M., Hood, K. K., Leverenz, B., Maahs, D. M. AMER DIABETES ASSOC. 2020
  • Early CGM Initiation Improves HbA1c in T1D Youth over the First 15 Months Prahalad, P., Ding, V., Addala, A., New, C., Conrad, B. P., Chmielewski, A., Geels, E., Leverenz, J., Martinez-Singh, A., Sagan, P., Senaldi, J., Freeman, A., Scheinker, D., Hood, K. K., Desai, M., Maahs, D. M. AMER DIABETES ASSOC. 2020
  • ISPAD Annual Conference 2019 Highlights. Pediatric diabetes Addala, A., March, C., Marks, B., Tommerdahl, K., Shapiro, J., Oyenusi, E., Yauch, L. M., Goethals, E. R., Ahmad, P. O., Adhami, S., Ng, M., Ehtisham, S., Agwu, J. C. 2020; 21 (2): 152–57

    View details for DOI 10.1111/pedi.12986

    View details for PubMedID 32022991

  • Improving Clinical Outcomes in Newly Diagnosed Pediatric Type 1 Diabetes: Teamwork, Targets, Technology, and Tight Control-The 4T Study. Frontiers in endocrinology Prahalad, P. n., Zaharieva, D. P., Addala, A. n., New, C. n., Scheinker, D. n., Desai, M. n., Hood, K. K., Maahs, D. M. 2020; 11: 360


    Many youth with type 1 diabetes (T1D) do not achieve hemoglobin A1c (HbA1c) targets. The mean HbA1c of youth in the USA is higher than much of the developed world. Mean HbA1c in other nations has been successfully modified following benchmarking and quality improvement methods. In this review, we describe the novel 4T approach-teamwork, targets, technology, and tight control-to diabetes management in youth with new-onset T1D. In this program, the diabetes care team (physicians, nurse practitioners, certified diabetes educators, dieticians, social workers, psychologists, and exercise physiologists) work closely to deliver diabetes education from diagnosis. Part of the education curriculum involves early integration of technology, specifically continuous glucose monitoring (CGM), and developing a curriculum around using the CGM to maintain tight control and optimize quality of life.

    View details for DOI 10.3389/fendo.2020.00360

    View details for PubMedID 32733375

    View details for PubMedCentralID PMC7363838

  • Unintended Consequences of COVID-19: Remember General Pediatrics. The Journal of pediatrics Cherubini, V. n., Gohil, A. n., Addala, A. n., Zanfardino, A. n., Iafusco, D. n., Hannon, T. n., Maahs, D. M. 2020

    View details for DOI 10.1016/j.jpeds.2020.05.004

    View details for PubMedID 32437758

    View details for PubMedCentralID PMC7207102

  • 50 Years Ago in The Journal of Pediatrics: Gluconeogenesis and Insulin in the Ketotic Variety of Childhood Hypoglycemia and in Control Children. The Journal of pediatrics Addala, A., Maahs, D. M. 2019; 207: 122

    View details for DOI 10.1016/j.jpeds.2018.09.068

    View details for PubMedID 30922489

  • Gluconeogenesis and Insulin in the Ketotic Variety of Childhood Hypoglycemia and in Control Children JOURNAL OF PEDIATRICS Addala, A., Maahs, D. M. 2019; 207: 122
  • Depression in Context: Important Considerations for Youth with Type 1 vs Type 2 Diabetes. Pediatric diabetes Wong, J. J., Addala, A. n., Abujaradeh, H. n., Adams, R. N., Barley, R. C., Hanes, S. J., Iturralde, E. n., Lanning, M. S., Naranjo, D. n., Tanenbaum, M. L., Hood, K. K. 2019


    Youth with diabetes are at increased risk for depression. However, severity and correlates of depressive symptoms may differ by diabetes type.Associations of depressive symptoms with global health, diabetes duration, and gender were compared between youth with type 1 and type 2 diabetes.A sample of 149 youth ages 12-21 diagnosed with either type 1 (n = 122) or type 2 (n = 27) diabetes were screened during routine clinic appointments. Regression models were constructed to examine differences by diabetes type.Adolescents with type 2 diabetes had significantly higher depressive symptom scores (4.89 vs 2.99, P = 0.025) than those with type 1 diabetes. A significant interaction between global health and diabetes type on depressive symptoms revealed inverse associations between global health and depressive symptoms that was stronger among youth with type 2 diabetes (β = -0.98, P < 0.001) than type 1 (β = -0.48, P < 0.001). Further probing revealed that among youth with better global health, adolescents with type 1 had more depressive symptoms than those with type 2 diabetes (β = 0.33, P = 0.035). Diabetes duration and depressive symptoms were positively associated among individuals with type 2 (β = 0.86, P = 0.043), but not type 1 diabetes. No gender differences were detected.These findings suggest that correlates of depressive symptoms in youth with diabetes differ by diabetes type. Global health appears to be an important correlate among youth with both types, whereas diabetes duration was only a significant factor among those with type 2 diabetes. The current findings can inform future psychosocial intervention efforts within both these populations. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1111/pedi.12939

    View details for PubMedID 31644828

  • CGM Initiation Soon After Type 1 Diabetes Diagnosis Results in Sustained CGM Use and Wear Time. Diabetes care Prahalad, P. n., Addala, A. n., Scheinker, D. n., Hood, K. K., Maahs, D. M. 2019

    View details for DOI 10.2337/dc19-1205

    View details for PubMedID 31558548

  • The Interplay of Type 1 Diabetes and Weight Management: A Qualitative Study Exploring Thematic Progression from Adolescence to Young Adulthood. Pediatric diabetes Addala, A. n., Igudesman, D. n., Kahkoska, A. R., Muntis, F. R., Souris, K. J., Whitaker, K. J., Pratley, R. E., Mayer-Davis, E. n. 2019


    The impact of weight management in persons with type 1 diabetes (T1D) from childhood into adulthood has not been well-described. The purpose of the study was to explore qualitative themes presented by young adults with T1D with respect to the dual management of weight and T1D.We analyzed focus group data from 17 young adults with T1D (65% female, age 21.7 ± 2.1 years, HbA1c 8.1% ± 1.5) via inductive qualitative analysis methods. Major themes were compared to themes presented by youth with T1D ages 13-16 years in previously published study in order to categorize thematic progression from early adolescence through adulthood.Themes from young adults with T1D, when compared to those from youth, were categorized as: (1) persistent and unchanged themes, (2) evolving themes, and (3) newly-reported themes. Hypoglycemia and a sense of futility around exercise was an unchanged theme. Importance of insulin usage and a healthy relationship with T1D evolved to gather greater conviction. Newly reported themes are unique to integration of adulthood into T1D, such as family planning and managing T1D with work obligations. Young adults also reported negative experiences with providers in their younger years and desire for more supportive provider relationships.Issues identified by youth regarding the dual management of T1D and weight rarely resolve, but rather, persist or evolve to integrate other aspects of young adulthood. Individualized and age-appropriate clinical support and practice guidelines are warranted to facilitate the dual management of weight and T1D in persons with T1D. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1111/pedi.12903

    View details for PubMedID 31392807

  • Can Real World Evidence on Body Mass Index Trajectories Inform Clinical Practice? JOURNAL OF PEDIATRICS Addala, A., Maahs, D. M. 2018; 201: 10–11
  • Sustained Continuous Glucose Monitor Use in Low-Income Youth with Type 1 Diabetes Following Insurance Coverage Supports Expansion of Continuous Glucose Monitor Coverage for All. Diabetes technology & therapeutics Prahalad, P., Addala, A., Buckingham, B., Wilson, D. M., Maahs, D. M. 2018

    View details for PubMedID 30020810

  • Sustained Continuous Glucose Monitor Use in Low-Income Youth with Type 1 Diabetes Following Insurance Coverage Supports Expansion of Continuous Glucose Monitor Coverage for All DIABETES TECHNOLOGY & THERAPEUTICS Prahalad, P., Addala, A., Buckingham, B., Wilson, D. M., Maahs, D. M. 2018; 20 (9): 632–34
  • Can Real World Evidence on Body Mass Index Trajectories Inform Clinical Practice? The Journal of pediatrics Addala, A., Maahs, D. M. 2018

    View details for PubMedID 30025670