Association between attendance at an American diabetes camp and improvements in glycaemic control and treatment satisfaction

Abstract Introduction Few studies have evaluated glycaemic control using continuous glucose monitoring (CGM) in individuals before and after attendance at a diabetes camp or by comparing control groups at home to control groups at camp. Methods Youth (6–17 years) with T1D and receiving insulin therapy were enrolled at a week‐long diabetes camp. They participated in three clinic visits: at the start of a week at home, by initiating a Dexcom G6 CGM system; at the start of a week at camp, where the home week G6 was removed and a camp week G6 was inserted; and after camp, where the camp week G6 was removed. We administered Problem Areas in Diabetes (PAID) surveys at the second and third visits. Participants with <80% CGM data coverage or who did not complete all PAID surveys were excluded from analysis. We compared glycaemic control and PAID scores between the week at home and week at camp. Results Of 76 enrolled campers, 69 completed the study and 52 had results that qualified for analysis. The mean participant age was 12.5 ± 2.2 years. Camp was associated with significantly improved treatment satisfaction, time in desired glucose range and insulin sensitivity. Time in hyperglycaemia and basal insulin requirements decreased significantly. Conclusions Diabetes camp is associated with significant improvements in diabetes treatment satisfaction and glycaemic control compared to home care.

of life, [2][3][4] and haemoglobin A1c (HbA1c) levels. 5 However, few studies have examined whether glycaemic control at home prior to camp is different than that during camp. Additionally, previous studies have used point-of-care tests to measure glycaemic control. Studies using CGM systems are limited but valuable, because CGM data are quantitatively and qualitatively better than point-estimate finger stick glucose measurements or HbA1c. CGM data accurately assess the amount of time spent in the glucose target range of 70-180 mg/ dl, also called 'time in range' (TIR), and the time above or below this range in different settings, such as at home versus at camp. To our knowledge, no studies have examined these differences. We utilized an accurate, factory-calibrated, real-time CGM system to compare glycaemic control in home and camp settings.

| ME THODS
This prospective, non-randomized, observational study of youth ages 6-17 years was conducted at Barton Center week-long residential camps. Study participants were recruited from registrants for the Summer 2019 session. Inclusion criteria included English fluency and T1D managed with intensive insulin therapy (multiple daily injections or continuous subcutaneous insulin infusion). Exclusion criteria included type 2 diabetes (T2D) or use of an AID system; participants could use predictive low-glucose suspend insulin pump systems. The study was approved by a central institutional review board, and we obtained written informed consent. All procedures were in accordance with the ethical standards of the institutional review board and ethics committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1964, as revised in 2013.
The study included three visits with a Barton Center study team member. During the first clinic visit at the start of 'home week', we reviewed participant eligibility, obtained informed consent, recorded the participant's most recent HbA1c measurement and ini- During camp week, we set the G6 system to alarm when glucose concentrations were ≤55 mg/dl or ≥350 mg/dl and all systems were centrally monitored during the day and night by healthcare staff members. When glucose levels were outside the 55-350 mg/ dl range in the daytime or outside the 80-300 mg/dl range at nighttime, counsellors or medical staff performed confirmation finger stick glucose measurements and interventions such as blood ketone testing for hyperglycaemia. Otherwise, camp staff used G6 CGM data to inform treatment decisions.
Campers who had <80% CGM data coverage (predominantly due to loss of connectivity) or who did not complete all PAID questionnaires were excluded from the analysis. We compared satisfaction scores on PAID questionnaires and CGM-derived glycaemic measurements, including time spent in hypoglycaemia level 1 (<70 mg/ dl) or level 2 (<54 mg/dl), TIR and time spent in hyperglycaemia level 1 (>180 mg/dl) or level 2 (>250 mg/dl), between the home week and camp week. The Shapiro-Wilk test was used to determine whether data were distributed normally. We analysed normally distributed data with a paired Student's t-test and non-normally distributed data with the Wilcoxon signed rank test.

ACK N OWLED G EM ENTS
Supported by a grant from Dexcom, Inc. The authors thank Dr. David Harlan for his role in conducting the study and preparing the manuscript. The authors also thank Grace Mooshian for her help in conducting the study.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.