Trends in Prevalence of Type 1 and Type 2 Diabetes in Children and Adolescents in the US, 2001-2017

Childhood diabetes mellitus and early-onset kidney diseases later in life: a nationwide population-based matched cohort study

BACKGROUND

The empirical evidence remains inconclusive for an association between diabetes mellitus (DM) in children and early-onset kidney disease later in life, and little is known about the effects of DM types (i.e., type 1 diabetes [T1DM] and type 2 diabetes [T2DM]) in childhood on type-specific kidney diseases. We aimed to evaluate the association of childhood DM with overall and type-specific early-onset kidney diseases later in life.

METHODS

The population-based matched cohort study included 9356 individuals with DM (T1DM: 8470, T2DM: 886) diagnosed in childhood (< 18 years) who were born between 1977 and 2016, and 93,560 individuals without DM matched on sex and year of birth in Denmark. The main outcomes were overall and type-specific early-onset kidney diseases. The follow-up period of all included participants was from the date of DM diagnosis in the exposure group until the first diagnosis of kidney disease, emigration, or 31 December 2018, whichever came first.

RESULTS

During a median follow-up of 13 years, children with DM had a 154% increased risk of early-onset kidney diseases than children without DM (adjusted hazard ratios 2.54, 95% confidence intervals 2.38-2.72), and T1DM (2.48, 2.31-2.67) and T2DM (2.75, 2.28-3.31) showed similar results. Children with DM also had a higher risk of multiple specific kidney diseases including glomerular diseases, renal tubulo-interstitial diseases, renal failure, and urolithiasis. The risks of type-specific kidney diseases including glomerular diseases and renal failure tended to be higher for children with T2DM (glomerular diseases: 5.84, 3.69-9.24; renal failure: 14.77, 8.53-25.59) than those with T1DM (glomerular diseases: 3.14, 2.57-3.83; renal failure: 8.24, 6.66-10.20).

CONCLUSIONS

Children with DM had a higher increased risk of early-onset overall and specific kidney diseases later in life. Early prevention and treatment of both T1DM and T2DM in childhood may significantly reduce the risk of kidney diseases later in life.

Positive Additive and Multiplicative Interactions among Clustered Components of Metabolic Syndrome with Type 2 Diabetes Mellitus among Brazilian Adolescent Students

Background: It is still controversial whether the joint effect of Metabolic syndrome (MetS) components is greater than that expected based on their independent effects, regarding type 2 diabetes mellitus in adolescents. We evaluated additive and multiplicative interactions between pair-wise combinations of metabolic syndrome components regarding type 2 diabetes mellitus. Methods: We studied 37,815 Brazilian adolescents from a national school-based survey, The Study of Cardiovascular Risk Factors in Adolescents (Portuguese acronym, ERICA). A Poisson regression model was used to calculate sex-, age-, obesity-, smoking status-, sedentary behavior-, physical inactivity-, alcoholic consumption- and socioeconomic status-adjusted prevalence ratios to evaluate both additive and multiplicative interactions. Results: In the comparison of observed and expected joint effects, relative excess risk due to additive interaction (RERI) for high triglycerides and low high-density lipoprotein-cholesterol, high triglycerides and elevated waist circumference, elevated waist circumference and low high-density lipoprotein-cholesterol and elevated waist circumference and high blood pressure were 2.53 (−0.41, 5.46), 2.86 (−2.89, 8.61), 1.71 (−1.05, 4.46) and 0.97 (0.15, 1.79), respectively, thus suggesting additive interactions. Multiplicative interactions for those pairs of components were also observed, as expressed by interaction ratios > 1.0. Conclusions: The joint presence of some of the components of MetS showed a greater association with the prevalence of type 2 diabetes mellitus in adolescents than expected from the sum of their isolated effects. From a public health perspective, preventing one of the components of the pairs that interact may result in a greater reduction in the prevalence of T2DM than focusing on an individual component that does not interact with another component.

Hemorrhagic stroke: Uncommon complication of diabetic ketoacidosis in pediatric patients

Diabetic ketoacidosis (DKA) is a well-known complication of type 1 diabetes mellitus. Diabetic ketoacidosis predisposes patients into devastating neurological complications. The most common neurologic complication is cerebral edema. Stroke either ischemic or hemorrhagic are uncommon complications of DKA with worse patient's outcome. Hemorrhagic stroke can manifest as subarachnoid or intraparenchymal hemorrhage. We present a 14-year-girl presented with DKA and complicated with both subarachnoid and intraparenchymal hemorrhages. Owing to early diagnosis and prompt treatment the patient had good outcome.

Biogenic Amine Levels Markedly Increase in the Aqueous Humor of Individuals with Controlled Type 2 Diabetes

The composition of the aqueous humor of patients with type 2 diabetes is relevant to understanding the underlying causes of eye-related comorbidities. Information on the composition of aqueous humor in healthy subjects is limited due to the lack of adequate controls. To carry out a metabolomics study, 31 samples of aqueous humor from healthy subjects without ocular pathology, submitted to refractive surgery and seven samples from patients with type 2 diabetes without signs of ocular pathology related to diabetes were used. The level of 25 molecules was significantly (p < 0.001) altered in the aqueous humor of the patient group. The concentration of a single molecule, N-acetylornithine, makes it possible to discriminate between control and diabetes (sensitivity and specificity equal to 1). In addition, receptor operating characteristic curve and principal component analysis for the above-mentioned six molecules yielded significantly (p < 0.001) altered in the aqueous humor of the patient group. In addition, receptor operating characteristic curve and principal component analysis for six compounds yielded cut-off values and remarkable sensitivity, specificity, and segregation ability. The altered level of N-acetylornithine may be due to an increased amount of acetate in diabetes. It is of interest to further investigate whether this alteration is related to the pathogenesis of the disease. The increase in the amino form of pyruvate, alanine, in diabetes is also relevant because it could be a means of reducing the formation of lactate from pyruvate.

Associations Between Sleep and Metabolic Outcomes in Preadolescent Children

Context

Growing evidence suggests an important role for sleep for the metabolic health of children.

Objective

We aimed to determine how sleep is related to insulin sensitivity, insulin secretion, beta-cell function, and adiposity (BMI z-scores, body fat %, waist to height ratio) using objectively measured sleep and oral glucose tolerance test (OGTT)-derived measures.

Methods

Sixty-two children aged 7-11 years, born at Kaiser Permanente Southern California, wore wrist accelerometers for 7 days to objectively measure sleep, completed an OGTT, and had anthropometric measures (height [cm], weight [kg], waist [cm], body fat [%]) collected. Using linear regression, associations between Matsuda insulin sensitivity index (ISI), insulinogenic index (IGI), disposition index (DI), BMI z-score, waist to height ratio, and body fat % with sleep parameters [total sleep time (TST; min), sleep efficiency (SE; %), time in bed (TIB; min), wake after sleep onset (WASO; min), and sleep latency (SL; min)] were assessed. Body fat % was tested as a mediator of the relationship between TST and ISI.

Results

Longer TST was associated with better insulin sensitivity (P = 0.02), but not after adjusting for body fat %. Sleep parameters were not associated with IGI or DI. Longer TST was associated with lower % body fat (P = 0.01) and lower waist-to-height-ratios (P = 0.05). Body fat % explained 62% (P = 0.01) of the relationship between TST and ISI. Longer TIB was associated with lower adiposity measures (P < 0.05). There were no associations between SE, WASO, or SL and metabolic outcomes.

Conclusion

Objectively measured sleep duration was associated with lower adiposity, and the relationship between sleep duration and ISI appeared partly through adiposity levels in preadolescent children. Longer sleep duration may be important for metabolic health.

Characteristics of Type 2 Diabetes in Female and Male Youth

The incidence of type 2 diabetes in children is rising and carries a worse prognosis than in adults. The influence of sex on pediatric type 2 diabetes outcomes has not been well investigated. We studied 715 youth with type 2 diabetes diagnosed at a median age of 13.7 years and compared sex differences in demographic, clinical, and laboratory characteristics within the first year of diagnosis. Females diagnosed with type 2 diabetes were younger and at a higher stage of pubertal development than males, yet presented with lower A1Cs, a lower prevalence of diabetic ketoacidosis, and higher HDL cholesterol levels.

Preventing and diagnosing HIV-related comorbidities in adolescents

Adolescents with HIV are growing into adulthood and are at risk for comorbidities. Comorbidities in adolescents often go unrecognized, increasing morbidity and mortality, and contributing to poorer outcomes for youth with HIV. Youth with perinatally and nonperinatally acquired HIV are at risk of developing HIV-associated and non-HIV comorbidities, including cardiovascular diseases, diabetes, mental health disorders, renal diseases, and bone disorders. Youth with HIV are also at risk for altered fat distribution and weight gain associated with certain classes of antiretroviral therapy. Sexually transmitted infections from inconsistent condom use pose a sexual health challenge for youth with HIV. Prompt interventions through comprehensive history taking, physical exams, regular screening, and prevention and treatment of clinically evident comorbid conditions are needed to prevent progression and complications.

Role of Psychologists in Pediatric Endocrinology

The care of youth managed within pediatric endocrine clinics is complex and requires a multi- or interdisciplinary approach. Psychosocial aspects of chronic health conditions are well-documented. Clinical practice guidelines outline the importance of routine psychosocial screening and support for youth with diabetes and obesity. This article outlines the diverse role of psychologists in pediatric endocrinology, including screening, in-clinic intervention, outpatient psychological services, and inpatient consultation. Although research exists documenting the effectiveness of behavioral interventions to improve adherence and health-related quality of life, cost analysis research is emerging.

First STEPS: Primary Outcomes of a Randomized, Stepped-Care Behavioral Clinical Trial for Parents of Young Children With New-Onset Type 1 Diabetes

OBJECTIVE

Despite the emotional challenges of parental adjustment to a child's type 1 diabetes diagnosis and the unique complexities of early childhood, there are few programs designed to meet the needs of parents of young children at new onset. This study evaluated First STEPS (Study of Type 1 in Early childhood and Parenting Support), a stepped-care behavioral intervention designed to support parents' psychosocial functioning and promote children's glycemic outcomes.

RESEARCH DESIGN AND METHODS

Using a two-site randomized clinical trial design, parents (n = 157) of children aged 1-6 years completed baseline data within 2 months of diabetes diagnosis and were randomly assigned to intervention (n = 115) or usual care (n = 42) for 9 months. Intervention steps included: 1) peer parent coaching, with step-ups to 2) structured behavioral counseling and 3) professional consultations with a diabetes educator and psychologist, based on parent mood and child HbA1c. Participants completed follow-ups at 9 and 15 months postrandomization. Primary outcomes were parent depressive symptoms and child HbA1c.

RESULTS

Depressive symptoms improved in both groups, and intervention parents had significantly lower depressive symptoms at the 9- and 15-month follow-ups compared with usual care. HbA1c decreased in both groups, but there were no between-group differences at 9 or 15 months.

CONCLUSIONS

First STEPS improved parents' mood following young children's type 1 diabetes diagnosis. Results indicate likely benefits of parent coach support, supplemented by intervention intensifications, including behavioral intervention and diabetes education. This model has high potential for patient engagement. The absence of a medical intervention component may explain null findings for HbA1c; incorporating targeted behavioral support for intensive diabetes treatment may maximize intervention impact.

Pharmacotherapy in paediatric type 2 diabetes mellitus: a protocol for a systematic review and network meta-analysis of randomised trials

INTRODUCTION

The rates of type 2 diabetes mellitus (T2DM) in children and adolescents have risen globally over the past few years. While a few diabetes pharmacotherapies have been used in this population, their comparative benefits and harms are unclear. Thus, we will conduct a systematic review and network meta-analysis (NMA) of randomised controlled trials (RCTs) to compare the efficacy and safety of pharmacotherapies for managing paediatric T2DM.

METHODS AND ANALYSIS

We will include RCTs that enrolled T2DM patients ≤18 years of age and who were randomised to monotherapy or combination pharmacotherapies with or without lifestyle interventions. Comparator groups will include placebo or non-pharmacological treatments including lifestyle interventions.Treatment outcomes will include change from baseline in glycated haemoglobin A1c, body mass index z-score, weight, systolic/diastolic blood pressure, fasting plasma glucose, fasting insulin and lipid profiles, T2DM-related complications, as well as the incidence of treatment-related adverse events.Literature searches will be conducted in Medline, Embase, CINAHL, CENTRAL and Web of Science. We will also search the grey literature and the reference list of included trials and relevant reviews. Two reviewers will assess the eligibility of articles identified through our searches and will extract data from eligible studies independently. We will use a modified Cochrane instrument to evaluate the risk of bias. Disagreements will be resolved through consensus or arbitration by a third reviewer.A frequentist random-effects model will be used for conducting NMA. The quality of evidence will be assessed using the Confidence in Network Meta-Analysis platform. We will assess the effect modification through network meta-regression and subgroup analyses for sex, age at study inclusion, duration of T2DM, follow-up duration and risk of bias ratings.

ETHICS AND DISSEMINATION

This study will not require ethics approval. We will disseminate our findings through publication in a peer-reviewed journal and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42022310100.

Obesity in late adolescence and incident type 1 diabetes in young adulthood

AIMS/HYPOTHESIS

Studies in children have reported an association between increased BMI and risk for developing type 1 diabetes, but evidence in late adolescence is limited. We studied the association between BMI in late adolescence and incident type 1 diabetes in young adulthood.

METHODS

All Israeli adolescents, ages 16-19 years, undergoing medical evaluation in preparation for mandatory military conscription between January 1996 and December 2016 were included for analysis unless they had a history of dysglycaemia. Data were linked with information about adult onset of type 1 diabetes in the Israeli National Diabetes Registry. Weight and height were measured at study entry. Cox proportional models were applied, with BMI being analysed both as a categorical and as a continuous variable.

RESULTS

There were 777 incident cases of type 1 diabetes during 15,819,750 person-years (mean age at diagnosis 25.2±3.9 years). BMI was associated with incident type 1 diabetes. In a multivariable model adjusted for age, sex and sociodemographic variables, the HRs for type 1 diabetes were 1.05 (95% CI 0.87, 1.27) for the 50th-74th BMI percentiles, 1.41 (95% CI 1.11, 1.78) for the 75th-84th BMI percentiles, 1.54 (95% CI 1.23, 1.94) for adolescents who were overweight (85th-94th percentiles), and 2.05 (95% CI 1.58, 2.66) for adolescents with obesity (≥95th percentile) (reference group: 5th-49th BMI percentiles). One increment in BMI SD was associated with a 25% greater risk for incidence of type 1 diabetes (HR 1.25, 95% CI 1.17, 1.32).

CONCLUSIONS

Excessively high BMI in otherwise healthy adolescents is associated with increased risk for incident type 1 diabetes in early adulthood.

Youth-onset type 2 diabetes in Israel: A national cohort

BACKGROUND

Prevalence of youth-onset type 2 diabetes (T2D) has increased worldwide, paralleling the rise in pediatric obesity. Occurrence and clinical manifestations vary regionally and demographically.

OBJECTIVES

We assessed the incidence, and clinical and demographic manifestations of youth-onset T2D in Israel.

METHODS

In a national observational study, demographic, clinical, and laboratory data were collected from the medical records of children and adolescents, aged 10-18 years, diagnosed with T2D between the years 2008 and 2019.

RESULTS

The incidence of youth-onset T2D in Israel increased significantly from 0.63/100,000 in 2008 to 3.41/100,000 in 2019. The study cohort comprised 379 individuals (228 girls [59.7%], 221 Jews [58.3%], mean age 14.7 ± 1.9 years); 73.1% had a positive family history of T2D. Mean body mass index (BMI) z-score was 1.96 ± 0.7, higher in Jews than Arabs. High systolic (≥ 130 mmHg) and diastolic blood pressure (≥ 85 mmHg) were observed in 33.7% and 7.8% of patients, respectively; mean glycosylated hemoglobin (A1c) level at diagnosis was 8.8 ± 2.5%. Dyslipidemia, with high triglyceride (>150 mg/dl) and low HDL-c (<40 mg/dl) levels, was found in 45.6% and 56.5%, respectively. Microalbuminuria and retinopathy were documented at diagnosis, 15.2% and 1.9%, respectively) and increased (36.7% and 4.6%, respectively) at follow-up of 2.9 ± 2.1 years. Criteria of metabolic syndrome were met by 224 (62.2%) patients, and fatty liver documented in 65%, mainly Jews. Psychosocial comorbidity was found in 31%. Treatment with metformin (45.6%), insulin (20.6%), and lifestyle modification (18%) improved glycemic control.

CONCLUSION

Youth-onset T2D in Israel has increased significantly and presents a unique profile.

Effects of a Diabetes Prevention Program on Type 2 Diabetes Risk Factors and Quality of Life Among Latino Youths With Prediabetes: A Randomized Clinical Trial

IMPORTANCE

Latino youths are disproportionately impacted by prediabetes and type 2 diabetes (T2D). Lifestyle intervention is the first-line approach for preventing or delaying T2D among adults with prediabetes.

OBJECTIVE

To assess the efficacy of a diabetes prevention program among Latino youths aged 12 to 16 years with prediabetes.

DESIGN, SETTING, AND PARTICIPANTS

This 2-group parallel randomized clinical trial with 2:1 randomization assessed a lifestyle intervention against usual care among Latino youths with prediabetes and obesity with 6- and 12-month follow-up. The study was conducted at YMCA facilities in Phoenix, Arizona from May 2016 to March 2020.

INTERVENTION

Participants were randomized to lifestyle intervention (INT) or usual care control (UCC). The 6-month INT included 1 d/wk of nutrition and health education and 3 d/wk of physical activity. UCC included 2 visits with a pediatric endocrinologist and a bilingual, bicultural registered dietitian to discuss diabetes risks and healthy lifestyle changes.

MAIN OUTCOMES AND MEASURES

Insulin sensitivity, glucose tolerance, and weight-specific quality of life (YQOL-W) at 6- and 12-month follow-up.

RESULTS

A total of 117 Latino youths (mean [SD] age, 14 [1] years; 47 [40.1%] girls) were included in the analysis. Overall, 79 were randomized to INT and 38 to UCC. At 6 months, the INT led to significant decreases in mean (SE) 2-hour glucose (baseline: 144 [3] mg/dL; 6 months: 132 [3] mg/dL; P = .002) and increases in mean (SE) insulin sensitivity (baseline: 1.9 [0.2]; 6 months: 2.6 [0.3]; P = .001) and YQOL-W (baseline: 75 [2]; 6 months: 80 [2]; P = .006), but these changes were not significantly different from UCC (2-hour glucose: mean difference, -7.2 mg/dL; 95% CI, -19.7 to 5.3 mg/dL; P for interaction = .26; insulin sensitivity: mean difference, 0.1; 95% CI, -0.7 to 0.9; P for interaction = .79; YQOL-W: mean difference, 6.3; 95% CI, -1.1 to 13.7; P for interaction = .10, respectively). Both INT (mean [SE], -15 mg/dL [4.9]; P = .002) and UCC (mean [SE], -15 mg/dL [5.4]; P = .005) had significant 12-month reductions in 2-hour glucose that did not differ significantly from each other (mean difference, -0.3; 95% CI, -14.5 to 14.1 mg/dL; P for interaction = .97). At 12 months, changes in mean (SE) insulin sensitivity in INT (baseline: 1.9 [0.2]; 12 months: 2.3 [0.2]; P = .06) and UCC (baseline: 1.9 [0.3]; 12 months: 2.0 [0.2]; P = .70) were not significantly different (mean difference, 0.3; 95% CI, -0.4 to 1.0; P for interaction = .37). At 12 months, YQOL-W was significantly increased in INT (basline: 75 [2]; 12 months: 82 [2]; P < .001) vs UCC (mean difference, 8.5; 95% CI, 0.8 to 16.2; P for interaction = .03).

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, both INT and UCC led to similar changes in T2D risk factors among Latino youths with diabetes; however, YQOL-W was improved in INT compared with UCC. Diabetes prevention interventions that are effective in adults also appeared to be effective in high risk youths.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02615353.

Sex Differences in Physical Activity Among Individuals With Type 2 Diabetes Across the Life Span: A Systematic Review and Meta-analysis

BACKGROUND

Physical activity (PA) is a cornerstone of type 2 diabetes mellitus (T2DM) treatment. Sex differences in PA behavior or barriers/facilitators to PA among individuals with T2DM are unclear.

PURPOSE

To summarize the evidence related to sex differences in participation in PA and barriers/facilitators to PA among individuals with T2DM across the life span.

DATA SOURCES

Systematic searches (CRD42021254246) were conducted with Ovid MEDLINE, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine Database (AMED), APA PsychInfo, and SPORTDiscus.

STUDY SELECTION

We included studies with assessment of PA, sedentary behaviors (SB), or barriers/facilitators to PA among individuals with T2DM by sex or gender.

DATA EXTRACTION

Participant characteristics, meeting PA guidelines, participation in PA and SB, and barriers/facilitators to PA were extracted by two independent reviewers.

DATA SYNTHESIS

A total of 53 articles (65,344 participants) were included in the systematic review and 21 articles in the meta-analysis. Sex differences were not observed in meeting of PA guidelines among adolescents (odds ratio 0.70 [95% CI 0.31, 1.59]), but males were more likely than females to meet PA guidelines among adults (1.65 [1.36, 2.01]) and older adults (1.63 [1.27, 2.09]). Males performed more moderate-to-vigorous PA (MVPA) than females across all age-groups. Common barriers to PA were lack of time (men) and lack of social support and motivation (women).

LIMITATIONS

Limitations include heterogeneity of measures used to assess PA and lack of stratification of data by sex.

CONCLUSIONS

Sex differences in meeting PA guidelines were not observed among adolescents but were apparent among adults and older adults with T2DM. Females consistently engaged in less MVPA than males across the life span.

Alterations in epidermal function in type 2 diabetes: Implications for the management of this disease

Epidermal function is regulated by numerous exogenous and endogenous factors, including age, psychological stress, certain skin disorders, ultraviolet irradiation and pollution, and epidermal function itself can regulate cutaneous and extracutaneous functions. The biophysical properties of the stratum corneum reflect the status of both epidermal function and systemic conditions. Type 2 diabetes in both murine models and humans displays alterations in epidermal functions, including reduced levels of stratum corneum hydration and increased epidermal permeability as well as delayed permeability barrier recovery, which can all provoke and exacerbate cutaneous inflammation. Because inflammation plays a pathogenic role in type 2 diabetes, a therapy that improves epidermal functions could be an alternative approach to mitigating type 2 diabetes and its associated cutaneous disorders.

Factors Affecting High-Risk for Diabetes among Korean Adolescents: An Analysis Using the Eighth Korea National Health and Nutrition Examination Survey (2020)

The purpose of this study was to identify significant factors affecting diabetes and pre-diabetes in South Korean adolescents, including adolescents’ and parental factors. We used data on 416 Korean adolescents aged 12–18 years and their parents (302 fathers and 375 mothers) from the eighth National Health and Nutrition Examination Survey gained in 2020. The data were analyzed by descriptive statistics, t-test, Rao–Scott χ² test, and univariate logistic regression using complex sample analysis. Among the participants, 101 adolescents (22.7%) were classified as the high-risk group for diabetes. Significant factors affecting the risk for adolescent diabetes in both sexes were higher BMI, fasting plasma glucose, hemoglobin A1c, and insulin. The father’s high degree of stress perception was only related to male adolescents, and the father’s poor subjective health status was related to females at risk for diabetes. In mothers, physician-diagnosed diabetes, fasting plasma glucose, and hemoglobin A1c were factors affecting both sexes. Results from this study can be used as preliminary data for the early detection of high-risk groups for diabetes in adolescents, and for the development of systematic health care guidelines to prevent diabetes in adolescents.

Diabetic kidney disease in pediatric patients: A current review

In the last decades, a significant increase in the incidence of diabetic kidney disease (DKD) was observed concomitant with rising diabetes mellitus (DM) incidence. Kidney disease associated with DM in children and adolescents is represented by persistent albuminuria, arterial hypertension, progressive decline in estimated glomerular filtration rate to end-stage renal disease and increased cardiovascular and all-cause morbidity and mortality of these conditions. In medical practice, the common and still the “gold standard” marker for prediction and detection of diabetic kidney involvement in pediatric diabetes is represented by microalbuminuria screening even if it has low specificity to detect early stages of DKD. There are some known limitations in albuminuria value as a predictor biomarker for DKD, as not all diabetic children with microalbuminuria or macroalbuminuria will develop end-stage renal disease. As tubular damage occurs before the glomerular injury, tubular biomarkers are superior to the glomerular ones. Therefore, they may serve for early detection of DKD in both type 1 DM and type 2 DM. Conventional and new biomarkers to identify diabetic children and adolescents at risk of renal complications at an early stage as well as renoprotective strategies are necessary to delay the progression of kidney disease to end-stage kidney disease. New biomarkers and therapeutic strategies are discussed as timely diagnosis and therapy are critical in the pediatric diabetic population.

Cardiovascular Disease Projections in the United States Based on the 2020 Census Estimates

BACKGROUND

Understanding trends in cardiovascular (CV) risk factors and CV disease according to age, sex, race, and ethnicity is important for policy planning and public health interventions.

OBJECTIVES

The goal of this study was to project the number of people with CV risk factors and disease and further explore sex, race, and ethnical disparities.

METHODS

The prevalence of CV risk factors (diabetes mellitus, hypertension, dyslipidemia, and obesity) and CV disease (ischemic heart disease, heart failure, myocardial infarction, and stroke) according to age, sex, race, and ethnicity was estimated by using logistic regression models based on 2013-2018 National Health and Nutrition Examination Survey data and further combining them with 2020 U.S. Census projection counts for years 2025-2060.

RESULTS

By the year 2060, compared with the year 2025, the number of people with diabetes mellitus will increase by 39.3% (39.2 million [M] to 54.6M), hypertension by 27.2% (127.8M to 162.5M), dyslipidemia by 27.5% (98.6M to 125.7M), and obesity by 18.3% (106.3M to 125.7M). Concurrently, projected prevalence will similarly increase compared with 2025 for ischemic heart disease by 31.1% (21.9M to 28.7M), heart failure by 33.0% (9.7M to 12.9M), myocardial infarction by 30.1% (12.3M to 16.0M), and stroke by 34.3% (10.8M to 14.5M). Among White individuals, the prevalence of CV risk factors and disease is projected to decrease, whereas significant increases are projected in racial and ethnic minorities.

CONCLUSIONS

Large future increases in CV risk factors and CV disease prevalence are projected, disproportionately affecting racial and ethnic minorities. Future health policies and public health efforts should take these results into account to provide quality, affordable, and accessible health care.

A computational framework for discovering digital biomarkers of glycemic control

Digital biomarkers can radically transform the standard of care for chronic conditions that are complex to manage. In this work, we propose a scalable computational framework for discovering digital biomarkers of glycemic control. As a feasibility study, we leveraged over 79,000 days of digital data to define objective features, model the impact of each feature, classify glycemic control, and identify the most impactful digital biomarkers. Our research shows that glycemic control varies by age group, and was worse in the youngest population of subjects between the ages of 2–14. In addition, digital biomarkers like prior-day time above range and prior-day time in range, as well as total daily bolus and total daily basal were most predictive of impending glycemic control. With a combination of the top-ranked digital biomarkers, we achieved an average F1 score of 82.4% and 89.7% for classifying next-day glycemic control across two unique datasets.

School Nursing Workforce Differences Between Urban and Non-Urban Areas: Implications for School Health Services and Equity

The professional experiences of school nurses who work outside of urban areas are not often described. We used data from a 2019 statewide survey of school nurses to describe differences between the urban and non-urban (urban cluster and rural) school nurse workforce in New Mexico. Non-urban school nurses were twice as likely as urban nurses to provide clinical services to multiple school campuses (P < .001) and more likely to serve both elementary and secondary school settings (P = .002). They were less likely than urban school nurses to be bachelor's prepared, or to have received recent continuing education on diabetes (P < .001), reproductive health (P = 0.02), LGBQ+ and transgender student health (P < .001, for each), and suicide risk assessment and screening (P = .012). Our findings underscore concerns about geographic differences in the school nursing workforce in terms of educational preparation and student access that could potentially limit the school nurse role in advancing child health equity.

Once-Weekly Dulaglutide for the Treatment of Youths with Type 2 Diabetes

BACKGROUND

The incidence of type 2 diabetes mellitus is increasing among youths. Once-weekly treatment with dulaglutide, a glucagon-like peptide-1 receptor agonist, may have efficacy with regard to glycemic control in youths with type 2 diabetes.

METHODS

In a double-blind, placebo-controlled, 26-week trial, we randomly assigned participants (10 to <18 years of age; body-mass index [BMI], >85th percentile) being treated with lifestyle modifications alone or with metformin, with or without basal insulin, in a 1:1:1 ratio to receive once-weekly subcutaneous injections of placebo, dulaglutide at a dose of 0.75 mg, or dulaglutide at a dose of 1.5 mg. Participants were then included in a 26-week open-label extension study in which those who had received placebo began receiving dulaglutide at a weekly dose of 0.75 mg. The primary end point was the change from baseline in the glycated hemoglobin level at 26 weeks. Secondary end points included a glycated hemoglobin level of less than 7.0% and changes from baseline in the fasting glucose concentration and BMI. Safety was also assessed.

RESULTS

A total of 154 participants underwent randomization. At 26 weeks, the mean glycated hemoglobin level had increased in the placebo group (0.6 percentage points) and had decreased in the dulaglutide groups (-0.6 percentage points in the 0.75-mg group and -0.9 percentage points in the 1.5-mg group, P<0.001 for both comparisons vs. placebo). At 26 weeks, a higher percentage of participants in the pooled dulaglutide groups than in the placebo group had a glycated hemoglobin level of less than 7.0% (51% vs. 14%, P<0.001). The fasting glucose concentration increased in the placebo group (17.1 mg per deciliter) and decreased in the pooled dulaglutide groups (-18.9 mg per deciliter, P<0.001), and there were no between-group differences in the change in BMI. The incidence of gastrointestinal adverse events was higher with dulaglutide therapy than with placebo. The safety profile of dulaglutide was consistent with that reported in adults.

CONCLUSIONS

Treatment with dulaglutide at a once-weekly dose of 0.75 mg or 1.5 mg was superior to placebo in improving glycemic control through 26 weeks among youths with type 2 diabetes who were being treated with or without metformin or basal insulin, without an effect on BMI. (Funded by Eli Lilly; AWARD-PEDS ClinicalTrials.gov number, NCT02963766.).

Mechanistic Insights Into the Heterogeneity of Glucose Response Classes in Youths With Obesity: A Latent Class Trajectory Approach

OBJECTIVE

In a large, multiethnic cohort of youths with obesity, we analyzed pathophysiological and genetic mechanisms underlying variations in plasma glucose responses to a 180 min oral glucose tolerance test (OGTT).

RESEARCH DESIGN AND METHODS

Latent class trajectory analysis was used to identify various glucose response profiles to a nine-point OGTT in 2,378 participants in the Yale Pathogenesis of Youth-Onset T2D study, of whom 1,190 had available TCF7L2 genotyping and 358 had multiple OGTTs over a 5 year follow-up. Insulin sensitivity, clearance, and β-cell function were estimated by glucose, insulin, and C-peptide modeling.

RESULTS

Four latent classes (1 to 4) were identified based on increasing areas under the curve for glucose. Participants in class 3 and 4 had the worst metabolic and genetic risk profiles, featuring impaired insulin sensitivity, clearance, and β-cell function. Model-predicted probability to be classified as class 1 and 4 increased across ages, while insulin sensitivity and clearance showed transient reductions and β-cell function progressively declined. Insulin sensitivity was the strongest determinant of class assignment at enrollment and of the longitudinal change from class 1 and 2 to higher classes. Transitions between classes 3 and 4 were explained only by changes in β-cell glucose sensitivity.

CONCLUSIONS

We identified four glucose response classes in youths with obesity with different genetic risk profiles and progressive impairment in insulin kinetics and action. Insulin sensitivity was the main determinant in the transition between lower and higher glucose classes across ages. In contrast, transitions between the two worst glucose classes were driven only by β-cell glucose sensitivity.

Prevalence trends of type 1 and type 2 diabetes in children and adolescents in North Rhine-Westphalia, the most populous federal state in Germany, 2002-2020

AIMS

To estimate the prevalence and temporal trends of type 1 and type 2 diabetes mellitus in children and adolescents (type 1 diabetes: 0-19 years, type 2 diabetes: 10-19 years) in North Rhine-Westphalia (NRW), Germany, from 2002 to 2020.

METHODS

The NRW Diabetes Registry records new cases based on three data sources (median completeness of ascertainment 99% for type 1 diabetes, 94% for type 2 diabetes). We determined age- and/or sex-standardized prevalence estimates (95% confidence intervals) per 100,000 individuals. Differences in age and sex, as well as time trends, were examined by Poisson regression. Furthermore, joinpoint regression was used to evaluate changes in prevalence trends over time.

RESULTS

At the end of 2020, the estimated type 1 diabetes prevalence was 247.1 (240.3; 253.9) with an annual increase of 2.9% (2.7%; 3.1%). The type 2 diabetes prevalence was 12.7 (10.6; 14.9) and increased by 6.4% (5.6%; 7.3%) per year. The prevalence trends were not uniform over the total period and flattened considerably in recent years.

CONCLUSIONS

The prevalence of type 1 and type 2 diabetes has increased significantly but at a lower rate in recent years. Continued surveillance of the prevalence is essential for the planning of health care resources and prevention measures.

Retinal Microvascular and Neuronal Changes Are Also Present, Even If Differently, in Adolescents with Type 1 Diabetes without Clinical Diabetic Retinopathy

The purpose of this study was to evaluate retinal changes in adolescents with childhood-onset, long-lasting type 1 diabetes mellitus (T1D). Patients and healthy controls (HC) underwent optical coherence tomography (OCT) and OCT-angiography (OCTA). Individual macular layers, peripapillary retinal nerve fiber layer (pRNFL), and vascular parameters (vessel area density (VAD), vessel length fraction (VLF) and vessel diameter index (VDI)) of macular superficial vascular (SVP), intermediate (ICP), deep (DCP) and radial peripapillary capillary plexuses (RPCP) were quantified. Thirty-nine patients (5 with (DR group) and 34 without (noDR group) diabetic retinopathy) and 20 HC were enrolled. The pRNFL and ganglion cell layer (GCL) were thicker in noDR compared to HC and DR, reaching statistically significant values versus HC for some sectors. At the macular level, VAD and VLF were reduced in DR versus HC in all plexuses, and versus noDR in SVP (p < 0.005 for all). At the RPCP level, VAD and VDI were increased in noDR versus HC, significantly for VDI (p = 0.0067). Glycemic indices correlated to retinal parameters. In conclusion, in T1D adolescents, retinal capillary and neuronal changes are present after long-lasting disease, even in the absence of clinical DR. These changes modify when clinical retinopathy develops. The precocious identification of specific OCT and OCTA changes may be a hallmark of subsequent overt retinopathy.

Assessment of Underuse and Overuse of Screening Tests for Co-occurring Conditions Among Children With Obesity

IMPORTANCE

The American Academy of Pediatrics (AAP) recommends laboratory screening for diabetes, dyslipidemia, and liver disease every 2 years among children aged 10 years and older with obesity. Routine screening for hypothyroidism or hyperinsulinemia is not recommended. National data on rates of adherence to AAP-recommended screening and rates of potentially unnecessary endocrine testing are unavailable.

OBJECTIVE

To assess rates of AAP-adherent screening and potentially unnecessary endocrine testing among privately and publicly insured children diagnosed with obesity at well-child visits.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used data from the 2018-2019 IBM MarketScan Commercial Database (which contains claims from privately insured patients across the US) and the 2018-2019 IBM MarketScan Multi-State Medicaid Database (which contains claims from Medicaid patients in multiple states). A total of 156 773 children aged 10 to 18 years with obesity diagnosis codes at a well-child visit from December 1, 2018, through November 30, 2019, were included. Analysis was performed from May 1 to October 31, 2021.

MAIN OUTCOMES AND MEASURES

Primary outcomes were the proportion of children who received AAP-adherent screening during the 729 days before to 30 days after a well-child visit and the proportion of children who received 1 or more potentially unnecessary thyroid or insulin tests during the same period. Proportions of children by payer type were compared using logistic regression models adjusted for age and sex. To assess screening that was potentially ordered by primary care clinicians, the proportion of children without AAP-adherent screening before visits who received this screening within 30 days was calculated.

RESULTS

Of 156 773 children, the mean (SD) age was 13.5 years (2.5) years; 83 305 (53.1%) were male, and 97 595 (62.3%) were publicly insured. Among publicly insured children, 13 167 (13.5%) were Hispanic or Latino, 34 792 (35.6%) were non-Hispanic Black, 42 029 (43.1%) were non-Hispanic White, 3850 (3.9%) were of other race and/or ethnicity (specific races and ethnicities were not available in the database), and 3757 (3.8%) were of unknown race and ethnicity. Race and ethnicity were not available for privately insured children because these data are not reported in the commercial claims database. During the 729 days before to 30 days after well-child visits, 42 849 patients (27.3%) received AAP-adherent screening, including 13 939 (23.6%) of 59 178 privately insured children and 28 910 (29.6%) of 97 595 publicly insured children (average marginal effect for public insurance: 6.8 [95% CI, 6.3-7.2] percentage points). In addition, 46 592 children (29.7%) received potentially unnecessary thyroid or insulin tests, including 12 834 (21.7%) of 59 178 privately insured children and 23 198 (23.8%) of 97 595 publicly insured children (average marginal effect for public insurance: 2.4 [95% CI, 2.0-2.8] percentage points). Among 129 104 children who did not receive AAP-adherent screening before visits, 15 090 (11.7%) received this screening within 30 days.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, similar proportions of children diagnosed with obesity at well-child visits received recommended and nonrecommended screening tests for obesity-related co-occurring conditions, suggesting that specific actionable guidelines and interventions are needed to prevent overuse and underuse of screening tests among children with obesity.

Five-Year Trends in US Children's Health and Well-being, 2016-2020

IMPORTANCE

Ensuring the well-being of the 73 million children in the United States is critical for improving the nation's health and influencing children's long-term outcomes as they grow into adults.

OBJECTIVE

To examine recent trends in children's health-related measures, including significant changes between 2019 and 2020 that might be attributed to the COVID-19 pandemic.

DESIGN, SETTING, AND PARTICIPANTS

Annual data were examined from the National Survey of Children's Health (2016-2020), a population-based, nationally representative survey of randomly selected children. Participants were children from birth to age 17 years living in noninstitution settings in all 50 states and the District of Columbia whose parent or caregiver responded to an address-based survey by mail or web. Weighted prevalence estimates account for probability of selection and nonresponse. Adjusted logistic regression models tested for significant trends over time.

MAIN OUTCOMES AND MEASURES

Diverse measures pertaining to children's current health conditions, positive health behaviors, health care access and utilization, and family well-being and stressors.

RESULTS

A total of 174 551 children were included (annual range = 21 599 to 50 212). Between 2016 and 2020, there were increases in anxiety (7.1% [95% CI, 6.6-7.6] to 9.2% [95% CI, 8.6-9.8]; +29%; trend P < .001) and depression (3.1% [95% CI, 2.9-3.5] to 4.0% [95% CI, 3.6-4.5]; +27%; trend P < .001). There were also decreases in daily physical activity (24.2% [95% CI, 23.1-25.3] to 19.8% [95% CI, 18.9-20.8]; -18%; trend P < .001), parent or caregiver mental health (69.8% [95% CI, 68.9-70.8] to 66.3% [95% CI, 65.3-67.3]; -5%; trend P < .001), and coping with parenting demands (67.2% [95% CI, 66.3-68.1] to 59.9% [95% CI, 58.8-60.9]; -11%; trend P < .001). In addition, from 2019 to 2020, there were increases in behavior or conduct problems (6.7% [95% CI, 6.1-7.4] to 8.1% [95% CI, 7.5-8.8]; +21%; P = .001) and child care disruptions affecting parental employment (9.4% [95% CI, 8.0-10.9] to 12.6% [95% CI, 11.2-14.1]; +34%; trend P = .001) as well as decreases in preventive medical visits (81.0% [95% CI, 79.7-82.3] to 74.1% [95% CI, 72.9-75.3]; -9%; trend P < .001).

CONCLUSIONS AND RELEVANCE

Recent trends point to several areas of concern that can inform future research, clinical care, policy decision making, and programmatic investments to improve the health and well-being of children and their families. More analyses are needed to elucidate varying patterns within subpopulations of interest.

Neighborhood Conditions and Type 2 Diabetes Risk among Latino Adolescents with Obesity in Phoenix

Type 2 Diabetes (T2D) has reached epidemic levels among the pediatric population. Furthermore, disparities in T2D among youth are distributed in a manner that reflects the social inequality between population sub-groups. Here, we investigated the neighborhood determinants of T2D risk among a sample of Latino adolescents with obesity residing in Phoenix, Arizona (n = 133). In doing so we linked together four separate contextual data sources: the American Community Survey, the United States Department of Agriculture Food Access Research Atlas, the Arizona Healthy Community Map, and the National Neighborhood Data Archive to systematically analyze how and which neighborhood characteristics were associated with T2D risk factors as measured by fasting and 2-h glucose following a 75 g oral glucose tolerance test. Using linear regression models with and without individual/household covariates, we investigated how twenty-two housing and transportation sociodemographic and built and food environment characteristics were independently and jointly associated with T2D risk. The main finding from these analyses was the strong association between the density of fast food restaurants and 2-h glucose values (b = 2.42, p < 0.01). This association was independent of individual, household, and other neighborhood characteristics. Our results contribute to an increasingly robust literature demonstrating the deleterious influence of the neighborhood food environment, especially fast food, for T2D risk among Latino youth.

Dietary pH Enhancement Improves Metabolic Outcomes in Diet-Induced Obese Male and Female Mice: Effects of Beef vs. Casein Proteins

(1) Consumption of diets that are caloric dense but not nutrient dense have been implicated in metabolic diseases, in part through low-grade metabolic acidosis. Mitigation strategies through dietary intervention to alleviate acidosis have not been previously reported. Our objective is to determine the effects of pH enhancement (with ammonia) in high fat diet-induced obese mice that were fed beef or casein as protein sources compared to low fat diet-fed mice. (2) Methods: B6 male and female mice were randomized (n = 10) into eight diets that differ in protein source, pH enhancement of the protein, and fat content, and fed for 13 weeks: low fat (11% fat) casein (LFC), LF casein pH-enhanced (LFCN), LF lean beef (LFB), LFBN, high fat (46%) casein (HFC), HFCN, HF beef (HFB), and HFBN. Body weights and composition, and glucose tolerance tests were conducted along with terminal serum analyses. Three-way ANOVA was performed. (3) Results: A significant effect of dietary fat (LF vs. HF) was observed across all variables in both sexes (final body weight, fat mass, glucose clearance, and serum leptin). Importantly, pH enhancement significantly reduced adiposity (males only) and final body weights (females only) and significantly improved glucose clearance in both sexes. Lastly, clear sex differences were observed across all variables. (4) Conclusions: Our findings demonstrate metabolic benefits of increasing dietary pH using ammonia, while high fat intake per se (not protein source) is the major contributor to metabolic dysfunctions. Additional research is warranted to determine mechanisms underlying the beneficial effects of pH enhancement, and interactions with dietary fat content and proteins.

Young Children with Type 1 Diabetes: Recent Advances in Behavioral Research

PURPOSE OF REVIEW

This review provides a recent update of behavioral research pertinent to young children with T1D and addresses current priorities and future directions.

RECENT FINDINGS

Rates of type 1 diabetes (T1D) in young children (ages 1-7) are continuing to rise. Since 2014, changes to diabetes care and management have impacted young children and reinforced the need for increased attention and interventions to support diabetes management, especially in caregivers who are primarily responsible for their young child's diabetes management. T1D is associated with unique physiologic challenges in young children, with constant management demands elevating parental diabetes-related stress and fear of hypoglycemia. Diabetes technology use has significantly increased in young children, contributing to improvements in glycemic levels and parent and child psychosocial functioning. Yet despite the positive outcomes demonstrated in select clinical behavioral interventions, research with this young child age group remains limited in scope and quantity.

Demographic and diagnostic markers in new onset pediatric type 1 and type 2 diabetes: differences and overlaps

PURPOSE

Type 1 diabetes (T1D) is the most common type of diabetes in children, but the frequency of type 2 diabetes (T2D) is increasing rapidly. Classification of diabetes is based on a constellation of features that vary by type. We aimed to compare demographic, clinical, and laboratory characteristics at diagnosis of pediatric T1D and T2D.

METHODS

We studied children who visited a large academic hospital in Houston, Texas (USA) with a new diagnosis of T2D (n=753) or T1D (n=758). We compared age, sex, race/ethnicity, presence of obesity, glucose, hemoglobin A1c, islet autoantibody positivity, C-peptide, and presence of diabetic ketoacidosis (DKA) at diabetes diagnosis.

RESULTS

At diagnosis, children with T2D, compared with those with T1D, were older (13.6 years vs. 9.7 years), more likely female (63.2% vs. 47.8%), of racial/ethnic minority (91.1% vs. 42.3%), and obese (90.9% vs. 19.4%) and were less likely to have DKA (7.8% vs. 35.0%) and diabetes autoantibodies (5.5% vs. 95.4%). Children with T2D also had significantly lower glucose, lower hemoglobin A1c and lower C-peptide level (all comparisons, p<0.0001). In multiple logistic regression analysis, older age, racial/ethnic minority, obesity, higher C-peptide, and negative islet autoantibodies were independently associated with T2D (all, p<0.05), while sex, glucose, hemoglobin A1c, and DKA were not (model p<0.0001).

CONCLUSION

There are important demographic, clinical, and laboratory differences between T1D and T2D in children. However, none of the characteristics were unique to either diabetes type, which poses challenges to diabetes classification at diagnosis.

Fructose Intake, Hypertension and Cardiometabolic Risk Factors in Children and Adolescents: From Pathophysiology to Clinical Aspects. A Narrative Review

Arterial hypertension, dyslipidemia, alterations in glucose metabolism and fatty liver, either alone or in association, are frequently observed in obese children and may seriously jeopardize their health. For obesity to develop, an excessive intake of energy-bearing macronutrients is required; however, ample evidence suggests that fructose may promote the development of obesity and/or metabolic alterations, independently of its energy intake. Fructose consumption is particularly high among children, because they do not have the perception, and more importantly, neither do their parents, that high fructose intake is potentially dangerous. In fact, while this sugar is erroneously viewed favorably as a natural nutrient, its excessive intake can actually cause adverse cardio-metabolic alterations. Fructose induces the release of pro-inflammatory cytokines, and reduces the production of anti-atherosclerotic cytokines, such as adiponectin. Furthermore, by interacting with hunger and satiety control systems, particularly by inducing leptin resistance, it leads to increased caloric intake. Fructose, directly or through its metabolites, promotes the development of obesity, arterial hypertension, dyslipidemia, glucose intolerance and fatty liver. This review aims to highlight the mechanisms by which the early and excessive consumption of fructose may contribute to the development of a variety of cardiometabolic risk factors in children, thus representing a potential danger to their health. It will also describe the main clinical trials performed in children and adolescents that have evaluated the clinical effects of excessive intake of fructose-containing drinks and food, with particular attention to the effects on blood pressure. Finally, we will discuss the effectiveness of measures that can be taken to reduce the intake of this sugar.

Associations between persistent organic pollutants and type 1 diabetes in youth

BACKGROUND

Diabetes affects millions of people worldwide with a continued increase in incidence occurring within the pediatric population. The potential contribution of persistent organic pollutants (POPs) to diabetes in youth remains poorly known, especially regarding type 1 diabetes (T1D), generally the most prevalent form of diabetes in youth.

OBJECTIVES

We investigated the associations between POPs and T1D in youth and studied the impacts of POPs on pancreatic β-cell function and viability in vitro.

METHODS

We used data and plasma samples from the SEARCH for Diabetes in Youth Case Control Study (SEARCH-CC). Participants were categorized as Controls, T1D with normal insulin sensitivity (T1D/IS), and T1D with insulin resistance (T1D/IR). We assessed plasma concentrations of polychlorinated biphenyls (PCBs) and organochlorine pesticides and estimated the odds of T1D through multivariable logistic regression. In addition, we performed in vitro experiments with the INS-1E pancreatic β-cells. Cells were treated with PCB-153 or p,p'-DDE at environmentally relevant doses. We measured insulin production and secretion and assessed the mRNA expression of key regulators involved in insulin synthesis (Ins1, Ins2, Pdx1, Mafa, Pcsk1/3, and Pcsk2), glucose sensing (Slc2a2 and Gck), and insulin secretion (Abcc8, Kcnj11, Cacna1d, Cacna1b, Stx1a, Snap25, and Sytl4). Finally, we assessed the effects of PCB-153 and p,p'-DDE on β-cell viability.

RESULTS

Among 442 youths, 112 were controls, 182 were classified with T1D/IS and 148 with T1D/IR. The odds ratios (OR) of T1D/IS versus controls were statistically significant for p,p'-DDE (OR 2.0, 95% confidence interval (CI) 1.0, 3.8 and 2.4, 95% CI 1.2, 5.0 for 2nd and 3rd tertiles, respectively), trans-nonachlor (OR 2.5, 95% CI 1.3, 5.0 and OR 2.3, 95% CI 1.1, 5.1 for 2nd and 3rd tertiles, respectively), and PCB-153 (OR 2.3, 95% CI 1.1, 4.6 for 3rd tertile). However, these associations were not observed in participants with T1D/IR. At an experimental level, treatment with p,p'-DDE or PCB-153, at concentrations ranging from 1 × 10^-15 M to 5 × 10^-6 M, impaired the ability of pancreatic β-cells to produce and secrete insulin in response to glucose. These failures were paralleled by impaired Ins1 and Ins2 mRNA expression. In addition, among different targeted genes, PCB-153 significantly reduced Slc2a2 and Gck mRNA expression whereas p,p'-DDE mainly affected Abcc8 and Kcnj11. While treatment with PCB-153 or p,p'-DDE for 2 days did not affect β-cell viability, longer treatment progressively killed the β-cells.

CONCLUSION

These results support a potential role of POPs in T1D etiology and demonstrate a high sensitivity of pancreatic β-cells to POPs.

Assessment and Treatment of Adolescents With Chronic Medical Conditions

Chronic medical conditions persist for one year or more, require ongoing medical intervention, and impair functioning. Approximately 10-30% of youth are diagnosed with a chronic medical condition. Youth with chronic medical conditions are at heightened risk for psychiatric comorbidity and negative health outcomes across the lifespan. Managing a chronic medical condition becomes particularly difficult during the adolescent developmental period, which is marked by changes in biological, psychological, social, and cognitive development. Assessment and intervention with adolescents is often challenging, as this is a period of transition and risk. Given increasing rates of chronic medical conditions, health service psychologists are likely to encounter youth with medical conditions in their clinical practice. In this paper, an overview of chronic medical conditions and adolescent development is provided and fundamental assessment and treatment components, including multicultural considerations, are explored.

Are Clinicians Aggressive Enough in Treating Diabetes-Related Hyperlipidemia in Youth?

PURPOSE OF REVIEW

Cardiovascular disease is the leading cause of death in patients with type 1 diabetes (T1D) and type 2 diabetes (T2D). Subclinical atherosclerotic changes are noted in youth with diabetes; therefore, timely identification and management of modifiable cardiovascular risk factors including hyperlipidemia is crucial. We review the current guidelines for hyperlipidemia screening and treatment in youth with T1D and T2D. We discuss the efficacy of non-pharmacological strategies including dietary modifications, exercise, and glycemic control and pharmacological therapy. We summarize reported rates of treatment of diabetes-related hyperlipidemia in youth.

RECENT FINDINGS

Hyperlipidemia is prevalent among youth with T1D and T2D. Vast majority of youth with diabetes-related hyperlipidemia do not receive lipid-lowering treatments. There are several factors that contribute to suboptimal management of hyperlipidemia in youth with diabetes including limited data on efficacy and safety of statins in youth with diabetes. We propose strategies to improve hyperlipidemia management including education of providers and patients, quality improvement methods, and electronic health record alerts. Additionally, further studies are warranted to examine the safety of statins in youth with diabetes, cost-benefit analysis to aggressive screening and treatment, and long-term effect for improving cardiovascular morbidity and mortality.

Text Messages and Financial Incentives to Increase Physical Activity in Adolescents With Prediabetes and Type 2 Diabetes: Web-Based Group Interviews to Inform Intervention Design

BACKGROUND

Physical activity is a major component of treatment for adolescents with obesity and prediabetes or type 2 diabetes; however, sedentary behavior remains pervasive. An SMS text message-based intervention paired with financial incentives may be an effective way to promote physical activity in this population.

OBJECTIVE

This study aims to obtain end-user feedback on SMS text message content and assess the acceptability of a planned SMS text messaging intervention with financial incentives to motivate youth with prediabetes or type 2 diabetes to increase physical activity.

METHODS

Adolescents with overweight or obesity and prediabetes or type 2 diabetes who attended a large academic pediatric endocrinology clinic were recruited to participate in group interviews (2-4/group) via videoconferencing. Participants were asked to share their thoughts on the use of SMS text messages and financial incentives to remind and motivate them to be more physically active. They rated and provided feedback on specific messages to be used in clinical trials. Participants were also asked about their personal experience with rewards to motivate behavior change and their anticipated reactions to rewards provided for goal attainment (gain-framing) versus those provided and then taken away if a goal was not met (loss-framing). The interviews were conducted by 2 trained interviewers and a note-taker. Content analysis was used to explore themes.

RESULTS

Group interviews were completed with 20 participants (11/20, 55% women; 15/20, 75% with type 2 diabetes; 5/20, 25% with prediabetes) with a mean age of 15 (SD 1; range 12-18) years and a mean BMI of 41 (SD 5) kg/m² (all >95th percentile for age and sex). Most participants were non-Hispanic Black (14/20, 70%) and 10% (2/20) were Hispanics. Participants frequently cited near-continuous smartphone use and agreed that SMS text messages would serve as good reminders to be physically active, but the consensus about the need for short messages was strong. Favorable content included references to what they were likely to be doing when messages were sent (eg, homework or watching television) and messages that were upbeat or informative. Specific physical activity suggestions were rated favorably. Attitudes toward financial incentives varied, with differing opinions about whether loss-framed incentives would be motivating or discouraging. Many participants highlighted the role of intrinsic, rather than extrinsic, motivation in achieving and sustaining behavior change.

CONCLUSIONS

The engagement of adolescents with obesity and diabetes or prediabetes allowed for the refinement of SMS text messages for our planned intervention, with an emphasis on short, upbeat, relatable, and informative messages. Although an SMS text messaging intervention using financial incentives to motivate youth with prediabetes or type 2 diabetes to be more physically active is theoretically acceptable, the impact on actual activity levels in this population requires prospective evaluation in a clinical trial.

Incidence of New-Onset Type 1 Diabetes Among US Children During the COVID-19 Global Pandemic

This cross-sectional study assesses the incidence of new-onset type 1 diabetes among US children during the COVID-19 pandemic.

Pediatric Diabetes on the Rise: Trends in Incident Diabetes During the COVID-19 Pandemic

Context

The effects of the coronavirus disease 2019 (COVID-19) pandemic on the incident cases of pediatric type 1 diabetes (T1D) and type 2 diabetes (T2D) are not clear.

Objective

To identify trends in incidence and presentation of pediatric new-onset T1D and T2D during the COVID-19 pandemic.

Methods

A retrospective chart review was conducted. Demographics, anthropometrics, and initial laboratory results from patients ages 0 through 21 years who presented with new-onset diabetes to a pediatric tertiary care center were recorded.

Results

During the pandemic, incident cases of pediatric T1D increased from 31 in each of the prior 2 years to 46; an increase of 48%. Incident cases of pediatric T2D increased by 231% from 2019 to 2020. The number of incident cases of pediatric T2D increased significantly more than the number of incident cases of pediatric T1D (P = 0.009). Patients with T2D were more likely to present in diabetic ketoacidosis (DKA), though this was not statistically significant (P = 0.093). Severe DKA was higher compared with moderate DKA (P = 0.036) in incident cases of pediatric T2D. During the pandemic, for the first time, incident cases of T2D accounted for more than one-half of all newly diagnosed pediatric diabetes cases (53%).

Conclusions

There were more incident pediatric T1D and T2D cases as well as an increase in DKA severity in T2D at presentation during the COVID-19 pandemic. More importantly, incident T2D cases were higher than the incident T1D during the pandemic. This clearly suggests a disruption and change in the pediatric diabetes trends with profound individual and community health consequences.

Obesity I: Overview and molecular and biochemical mechanisms

Obesity is a chronic, relapsing condition characterized by excess body fat. Its prevalence has increased globally since the 1970s, and the number of obese and overweight people is now greater than those underweight. Obesity is a multifactorial condition, and as such, many components contribute to its development and pathogenesis. This is the first of three companion reviews that consider obesity. This review focuses on the genetics, viruses, insulin resistance, inflammation, gut microbiome, and circadian rhythms that promote obesity, along with hormones, growth factors, and organs and tissues that control its development. It shows that the regulation of energy balance (intake vs. expenditure) relies on the interplay of a variety of hormones from adipose tissue, gastrointestinal tract, pancreas, liver, and brain. It details how integrating central neurotransmitters and peripheral metabolic signals (e.g., leptin, insulin, ghrelin, peptide YY_3-36) is essential for controlling energy homeostasis and feeding behavior. It describes the distinct types of adipocytes and how fat cell development is controlled by hormones and growth factors acting via a variety of receptors, including peroxisome proliferator-activated receptor-gamma, retinoid X, insulin, estrogen, androgen, glucocorticoid, thyroid hormone, liver X, constitutive androstane, pregnane X, farnesoid, and aryl hydrocarbon receptors. Finally, it demonstrates that obesity likely has origins in utero. Understanding these biochemical drivers of adiposity and metabolic dysfunction throughout the life cycle lends plausibility and credence to the "obesogen hypothesis" (i.e., the importance of environmental chemicals that disrupt these receptors to promote adiposity or alter metabolism), elucidated more fully in the two companion reviews.

Effects of Isocaloric Fructose Restriction on Ceramide Levels in Children with Obesity and Cardiometabolic Risk: Relation to Hepatic De Novo Lipogenesis and Insulin Sensitivity

Sugar intake, particularly fructose, is implicated as a factor contributing to insulin resistance via hepatic de novo lipogenesis (DNL). A nine-day fructose reduction trial, controlling for other dietary factors and weight, in children with obesity and metabolic syndrome, decreased DNL and mitigated cardiometabolic risk (CMR) biomarkers. Ceramides are bioactive sphingolipids whose dysregulated metabolism contribute to lipotoxicity, insulin resistance, and CMR. We evaluated the effect of fructose reduction on ceramides and correlations between changes observed and changes in traditional CMR biomarkers in this cohort. Analyses were completed on data from 43 participants. Mean weight decreased (−0.9 ± 1.1 kg). The majority of total and subspecies ceramide levels also decreased significantly, including dihydroceramides, deoxyceramides and ceramide-1-phoshates. Change in each primary ceramide species correlated negatively with composite insulin sensitivity index (CISI). Change in deoxyceramides positively correlated with change in DNL. These results suggest that ceramides decrease in response to dietary fructose restriction, negatively correlate with insulin sensitivity, and may represent an intermediary link between hepatic DNL, insulin resistance, and CMR.

The Impact of Novel Anti-Diabetic Medications on CV Outcomes: A New Therapeutic Horizon for Diabetic and Non-Diabetic Cardiac Patients

It is estimated that in the past two decades the number of patients diagnosed with diabetes mellites (DM) has doubled. Despite significant progress in the treatment of cardiovascular disease (CVD), including novel anti-platelet agents, effective lipid-lowering medications, and advanced revascularization techniques, patients with DM still are least twice as likely to die of cardiovascular causes compared with their non-diabetic counterparts, and current guidelines define patients with DM at the highest risk for atherosclerotic cardiovascular disease and major adverse cardiovascular events (MACE). Over the last few years, there has been a breakthrough in anti-diabetic therapeutics, as two novel anti-diabetic classes have demonstrated cardiovascular benefit with consistently reduced MACE, and for some agents, also improvement in heart failure status as well as reduced cardiovascular and all-cause mortality. These include the sodium-glucose cotransporter-2 inhibitors and the glucagon-like peptide-1 receptor agonists. The benefits of these medications are thought to be derived not only from their anti-diabetic effect but also from additional mechanisms. The purpose of this review is to provide the everyday clinician a detailed review of the various agents within each class with regard to their specific characteristics and the effects on MACE and cardiovascular outcomes.

Peer-support intervention for African American and Latino parents to improve the glycemic control trajectory among school-aged children with type 1 diabetes: A pilot and feasibility protocol

Background Type 1 diabetes (T1D) is a common, chronic pediatric health condition with complicated management demands. African American and Latino children with T1D have troubling disparities in glycemic outcomes and acute complications. While there are empirically supported behavioral interventions to support disease management in youth with T1D, there are few that specifically aim to reduce health disparities in this population. While collaborative parent involvement with the child with T1D management tasks is important to promote optimal glycemic outcomes during childhood, our formative research identified multiple individual, family, and broader system factors that impede or facilitate collaborative parental involvement among African American and Latino parents of children with T1D. Methods This paper describes the development, design, and study protocol for the Type 1 Diabetes Empowerment And Management (TEAM) pilot trial. The TEAM intervention is a novel, group-based behavioral intervention designed to enhance collaborative involvement in T1D management for African American and Latino parents of children aged 5-10. This randomized pilot trial's primary aim is to evaluate the TEAM intervention's feasibility and acceptability. The secondary aim is to examine preliminary intervention outcomes (i.e., children's HbA1c, treatment adherence, collaborative parent involvement in T1D management, parent/child quality of life, and parent's diabetes-related distress, depressive symptoms, and self-efficacy) compared to usual T1D care. Discussion The trial will provide preliminary information about whether optimizing appropriate parent involvement during the school-age years may increase T1D treatment adherence and stabilize or improve glycemic control in African American and Latino school-aged children.

Longitudinal Association of Depressive Symptoms, Binge Eating, and Quality of Life With Cardiovascular Risk Factors in Young Adults With Youth-Onset Type 2 Diabetes: The TODAY2 Study

OBJECTIVE

To report the prevalence of depression, eating disorder symptoms, and impaired health-related quality of life (HRQOL) and examine their longitudinal associations with glycemia and diabetes complications in young adults with youth-onset type 2 diabetes.

RESEARCH DESIGN AND METHODS

Participants recruited over a 4-year period were enrolled at 15 clinical diabetes centers in the follow-up observational Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY2) study. From 2014-2020, prevalence of symptoms of depression, eating disorders, and HRQOL by sex, race/ethnicity, and baseline family income were assessed annually. Longitudinal relationships between assessments of glycemia and complications with psychiatric symptoms and HRQOL were evaluated in adjusted models.

RESULTS

Participants (n = 514) were 21.7 ± 2.5 years old with a diabetes duration of 8.6 ± 1.5 years in year 1 of TODAY 2 (2014). Symptoms of depression and impaired HRQOL were common and increased significantly over 6 years (14.0% to 19.2%, P = 0.003; and 13.1% to 16.7%, P = 0.009, respectively). Depression and impaired HRQOL were more common in women and those with lower baseline family income but did not differ by race/ethnicity. Rates of binge eating were stable over time; self-reported purging increased. Over time, symptoms of depression were associated with higher HbA1c, hypertension, and retinopathy progression; impaired HRQOL was associated with higher BMI, systolic blood pressure, hypertension, and retinopathy progression; and symptoms of eating disorders were associated with higher BMI.

CONCLUSIONS

Significant psychiatric symptoms and impaired HRQOL are common among emerging adults with youth-onset type 2 diabetes and are positively associated with glycemia, hypertension, and retinopathy progression in this group that is at ongoing risk for medical morbidity.

2022 National Standards for Diabetes Self-Management Education and Support

PURPOSE

The National Standards for Diabetes Self-Management Education and Support (DSMES) provide guidance and evidence-based, quality practice for all DSMES services. Due to the dynamic nature of health care and diabetes research, the National Standards are reviewed and revised approximately every 5 years by key stakeholders and experts within the diabetes care and education community. For each revision, the Task Force is charged with reviewing the current National Standards for appropriateness, relevance, and scientific basis and making updates based on current evidence and expert consensus. In 2021, the group was tasked with reducing administrative burden related to DSMES implementation across diverse care settings.

CONCLUSION

The evidence supporting the 2022 National Standards clearly identifies the need to provide person-centered services that embrace cultural differences, social determinants of health, and the ever-increasing technological engagement platforms and systems. Payers are invited to review the National Standards as a tool to inform and modernize DSMES reimbursement requirements and to align with the evolving needs of people with diabetes (PWD) and physicians/other qualified health care professionals. The American Diabetes Association and the Association of Diabetes Care & Education Specialists strongly advocate for health equity to ensure all PWD have access to this critical service proven to improve outcomes both related to and beyond diabetes. The 2022 National Standards update is meant to be a universal document that is easy to understand and can be implemented by the entire health care community. DSMES teams in collaboration with primary care have been shown to be the most effective approach to overcome therapeutic inertia.

Risk for Newly Diagnosed Diabetes >30 Days After SARS-CoV-2 Infection Among Persons Aged <18 Years - United States, March 1, 2020-June 28, 2021

The COVID-19 pandemic has disproportionately affected people with diabetes, who are at increased risk of severe COVID-19.* Increases in the number of type 1 diabetes diagnoses (1,2) and increased frequency and severity of diabetic ketoacidosis (DKA) at the time of diabetes diagnosis (3) have been reported in European pediatric populations during the COVID-19 pandemic. In adults, diabetes might be a long-term consequence of SARS-CoV-2 infection (4-7). To evaluate the risk for any new diabetes diagnosis (type 1, type 2, or other diabetes) >30 days† after acute infection with SARS-CoV-2 (the virus that causes COVID-19), CDC estimated diabetes incidence among patients aged <18 years (patients) with diagnosed COVID-19 from retrospective cohorts constructed using IQVIA health care claims data from March 1, 2020, through February 26, 2021, and compared it with incidence among patients matched by age and sex 1) who did not receive a COVID-19 diagnosis during the pandemic, or 2) who received a prepandemic non-COVID-19 acute respiratory infection (ARI) diagnosis. Analyses were replicated using a second data source (HealthVerity; March 1, 2020-June 28, 2021) that included patients who had any health care encounter possibly related to COVID-19. Among these patients, diabetes incidence was significantly higher among those with COVID-19 than among those 1) without COVID-19 in both databases (IQVIA: hazard ratio [HR] = 2.66, 95% CI = 1.98-3.56; HealthVerity: HR = 1.31, 95% CI = 1.20-1.44) and 2) with non-COVID-19 ARI in the prepandemic period (IQVIA, HR = 2.16, 95% CI = 1.64-2.86). The observed increased risk for diabetes among persons aged <18 years who had COVID-19 highlights the importance of COVID-19 prevention strategies, including vaccination, for all eligible persons in this age group,§ in addition to chronic disease prevention and management. The mechanism of how SARS-CoV-2 might lead to incident diabetes is likely complex and could differ by type 1 and type 2 diabetes. Monitoring for long-term consequences, including signs of new diabetes, following SARS-CoV-2 infection is important in this age group.