I am a physician scientist addressing disparities in type 1 diabetes management and outcomes. My research interests are at the intersection of type 1 diabetes and inequities evaluating system-, family-, and individual-level contributors to type 1 diabetes disparities. My longstanding research and clinical interests are to promote equitable care for youth with type 1 diabetes informed by the biological, social, psychological, and systemic determinants of health.
- Diabetes and Metabolism
Instructor, Pediatrics - Endocrinology and Diabetes
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
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
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
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.
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.
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
- CGM Initiation Soon After Type 1 Diabetes Diagnosis Results in Sustained CGM Use and Wear Time. Diabetes care 2019
- 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 2018; 20 (9): 632–34
Changes to Care Delivery at Nine International Pediatric Diabetes Clinics in Response to the COVID-19 Global Pandemic.
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
"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
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
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 AMER DIABETES ASSOC. 2020
- The Association between Time-in-Range, Mean Glucose, and Incidence of Hypoglycemia in Youth with Newly Diagnosed T1D AMER DIABETES ASSOC. 2020
- Early Introduction of Continuous Glucose Monitoring Is Well Accepted by Youth and Parents 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 AMER DIABETES ASSOC. 2020
- Early CGM Initiation Improves HbA1c in T1D Youth over the First 15 Months AMER DIABETES ASSOC. 2020
- ISPAD Annual Conference 2019 Highlights. Pediatric diabetes 2020; 21 (2): 152–57
Improving Clinical Outcomes in Newly Diagnosed Pediatric Type 1 Diabetes: Teamwork, Targets, Technology, and Tight Control-The 4T Study.
Frontiers in endocrinology
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 2020
Gluconeogenesis and Insulin in the Ketotic Variety of Childhood Hypoglycemia and in Control Children
JOURNAL OF PEDIATRICS
2019; 207: 122
View details for Web of Science ID 000462161200024
Depression in Context: Important Considerations for Youth with Type 1 vs Type 2 Diabetes.
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
The Interplay of Type 1 Diabetes and Weight Management: A Qualitative Study Exploring Thematic Progression from Adolescence to Young Adulthood.
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
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
2019; 207: 122
View details for PubMedID 30922489
- Can Real World Evidence on Body Mass Index Trajectories Inform Clinical Practice? JOURNAL OF PEDIATRICS 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
View details for PubMedID 30020810
Can Real World Evidence on Body Mass Index Trajectories Inform Clinical Practice?
The Journal of pediatrics
View details for PubMedID 30025670