Experience of a serious life event increases the risk for childhood type 1 diabetes: the ABIS population-based prospective cohort study

Physical activity, sedentary behaviour, and childhood asthma: a European collaborative analysis

OBJECTIVES

To investigate the associations of physical activity (PA) and sedentary behaviour in early childhood with asthma and reduced lung function in later childhood within a large collaborative study.

DESIGN

Pooling of longitudinal data from collaborating birth cohorts using meta-analysis of separate cohort-specific estimates and analysis of individual participant data of all cohorts combined.

SETTING

Children aged 0-18 years from 26 European birth cohorts.

PARTICIPANTS

136 071 individual children from 26 cohorts, with information on PA and/or sedentary behaviour in early childhood and asthma assessment in later childhood.

MAIN OUTCOME MEASURE

Questionnaire-based current asthma and lung function measured by spirometry (forced expiratory volume in 1 s (FEV1), FEV1/forced vital capacity) at age 6-18 years.

RESULTS

Questionnaire-based and accelerometry-based PA and sedentary behaviour at age 3-5 years was not associated with asthma at age 6-18 years (PA in hours/day adjusted OR 1.01, 95% CI 0.98 to 1.04; sedentary behaviour in hours/day adjusted OR 1.03, 95% CI 0.99 to 1.07). PA was not associated with lung function at any age. Analyses of sedentary behaviour and lung function showed inconsistent results.

CONCLUSIONS

Reduced PA and increased sedentary behaviour before 6 years of age were not associated with the presence of asthma later in childhood.

Prenatal exposure to environmental contaminants and cord serum metabolite profiles in future immune-mediated diseases

BACKGROUND

Prenatal exposure to environmental contaminants is a significant health concern because it has the potential to interfere with host metabolism, leading to adverse health effects in early childhood and later in life. Growing evidence suggests that genetic and environmental factors, as well as their interactions, play a significant role in the development of autoimmune diseases.

OBJECTIVE

In this study, we hypothesized that prenatal exposure to environmental contaminants impacts cord serum metabolome and contributes to the development of autoimmune diseases.

METHODS

We selected cord serum samples from All Babies in Southeast Sweden (ABIS) general population cohort, from infants who later developed one or more autoimmune-mediated and inflammatory diseases: celiac disease (CD), Crohn's disease (IBD), hypothyroidism (HT), juvenile idiopathic arthritis (JIA), and type 1 diabetes (T1D) (all cases, N = 62), along with matched controls (N = 268). Using integrated exposomics and metabolomics mass spectrometry (MS) based platforms, we determined the levels of environmental contaminants and metabolites.

RESULTS

Differences in exposure levels were found between the controls and those who later developed various diseases. High contaminant exposure levels were associated with changes in metabolome, including amino acids and free fatty acids. Specifically, we identified marked associations between metabolite profiles and exposure levels of deoxynivalenol (DON), bisphenol S (BPS), and specific per- and polyfluorinated substances (PFAS).

IMPACT STATEMENT

Abnormal metabolism is a common feature preceding several autoimmune and inflammatory diseases. However, few studies compared common and specific metabolic patterns preceding these diseases. Here we hypothesized that exposure to environmental contaminants impacts cord serum metabolome, which may contribute to the development of autoimmune diseases. We found differences in exposure levels between the controls and those who later developed various diseases, and importantly, on the metabolic changes associated with the exposures. High contaminant exposure levels were associated with specific changes in metabolome. Our study suggests that prenatal exposure to specific environmental contaminants alters the cord serum metabolomes, which, in turn, might increase the risk of various immune-mediated diseases.

Early environmental predictors for attention-deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD) and their co-occurrence: The prospective ABIS-Study

ADHD and ASD are highly heritable and show a high co-occurrence and persistence into adulthood. This study aimed to identify pre and perinatal risk factors, and early psychosocial exposures related to later diagnosis of ADHD, ASD, and their co-occurrence. 16,365 children born 1997-1999 and their families, involved in the prospective population-based ABIS study (All Babies in Southeast Sweden), were included in this sub-study. Pre and perinatal factors and early environmental psychosocial exposures were collected from parental-questionnaires at birth and 1-year follow-up. Diagnoses from birth up to 23 years of age were obtained from the Swedish National Diagnosis Register in 2020. The cumulative incidence of ADHD, ASD, and their co-occurrence in the ABIS-cohort Study were 4.6%, 1.7%, and 1.1%, respectively. Being male was associated with an increased risk for ADHD, ASD, and their co-occurrence (aOR 1.30, 1.56, and 1.91, respectively), while higher household income reduced it (aOR 0.82, 0.73, and 0.64). Serious life events during pregnancy (aOR 1.40) and maternal smoking (aOR 1.51) increased the risk of ADHD, while older maternal age (aOR 0.96), higher parental education (aOR 0.72 maternal and aOR 0.74 paternal) and longer exclusive breastfeeding (aOR 0.72) reduced it. Non-Swedish paternal nationality (aOR 0.40) and higher maternal education (aOR 0.74) were associated with a lower risk of ASD, while a family history of autoimmune diseases increased the risk of the co-occurrence of both disorders (aOR 1.62). Obtained results suggest that the etiology of ADHD, ASD, and their co-occurrence is independently associated with environmental psychosocial predictors. The co-occurrence seems to overlap the etiology of ADHD, in which psychosocial determinants have a larger role, however, it is also independently influenced by a family history of autoimmune diseases.

Living with and managing type 1 diabetes in humanitarian settings: A qualitative synthesis of lived experience and stakeholder tacit knowledge

Humanitarian health actors are beginning to better consider and manage non-communicable diseases, such as diabetes, in emergency and protracted crisis settings. However, a focus on the more globally prevalent type 2 diabetes (T2D) dominates. Blind spots prevail in the unmet needs for type 1 diabetes (T1D), a chronic autoimmune condition where individuals are unable to produce insulin, thereby dependent on lifelong insulin therapy and blood glucose management. Although some T1D management requirements overlap with those of T2D, the immediate risk of fatal complications following insulin therapy disruption, the earlier age of onset during childhood, adolescence or young adulthood, and its lower prevalence compared to T2D within communities and local health systems mean that T1D requires nuanced consideration and targeted interventions. Intending to inform program and policy design for people with T1D (PWT1D), we synthesized themes of lived experience from PLWT1D and their caregivers, and the tacit working knowledge of health providers and policymakers in the context of local humanitarian operations. Through a strategic search of health databases (up to July 2023), we identified 11 articles that include interview excerpts from PWT1D, caregivers, healthcare providers and policymakers about T1D management in humanitarian settings. We used reflexive thematic analysis to guide data extraction, coding, and synthesis, resulting in the identification of four overarching themes: food and insulin security, family relations, knowledge translation, and response to diagnosis. The narratives highlight harsh trade-offs made by PWT1D and their families in the face of insulin and food insecurity, as well as the damaging impact of low T1D education in families, communities and health systems. Targeted family and community-based solutions are urgently required, alongside systemic reforms and international collaboration to enable better T1D coping and management in humanitarian settings.

Breastfeeding decreases the risk of developing psoriasis through to early adulthood

BACKGROUND

Psoriasis is a genetically determined systemic skin disease, although environmental trigger factors are required for disease manifestation. Some of these triggers, such as stress, infections and drug exposure, have been identified.

OBJECTIVES

To explore the role of early nutrition as a risk factor for the development of psoriasis.

METHODS

Parents in the All Babies in Southeast Sweden (ABIS) prospective birth cohort (n = 16 415) answered questionnaires at birth and when their children were aged 1 and 3 years. A diagnosis of psoriasis was determined from the Swedish National Patient Register and National Drug Prescription Register. Statistical analyses were conducted using custom-written R scripts.

RESULTS

Individuals breastfed for < 4 months and who received infant formula before 4 months of age had a higher risk of psoriasis [odds ratio (OR) 1.84 (P = 0.02) and OR 1.88 (P = 0.02), respectively]. At the 3-year follow-up, the increased consumption of fish, especially from the Baltic Sea, increased the risk of psoriasis (OR 9.61; P = 0.003). In addition, the risk of psoriasis increased following the consumption of a large volume of milk (OR 2.53; P = 0.04).

CONCLUSIONS

Our study underscores, for the first time, the impact of very early nutrition on the manifestation of psoriasis through early adulthood. Exclusive breastfeeding for 4 months appears to be protective.

Early family socioeconomic status and asthma-related outcomes in school-aged children: Results from seven birth cohort studies

OBJECTIVE

To examine the associations between maternal education and household income during early childhood with asthma-related outcomes in children aged 9-12 years in the UK, the Netherlands, Sweden, Australia, the USA and Canada.

METHODS

Data on 31 210 children were obtained from 7 prospective birth cohort studies across six countries. Asthma-related outcomes included ever asthma, wheezing/asthma attacks and medication control for asthma. Relative social inequalities were estimated using pooled risk ratios (RRs) adjusted for potential confounders (child age, sex, mother ethnic background and maternal age) for maternal education and household income. The Slope Index of Inequality (SII) was calculated for each cohort to evaluate absolute social inequalities.

RESULTS

Ever asthma prevalence ranged from 8.3% (Netherlands) to 29.1% (Australia). Wheezing/asthma attacks prevalence ranged from 3.9% (Quebec) to 16.8% (USA). Pooled RRs for low (vs high) maternal education and low (vs high) household income were: ever asthma (education 1.24, 95% CI 1.13 to 1.37; income 1.28, 95% CI 1.15 to 1.43), wheezing/asthma attacks (education 1.14, 95% CI 0.97 to 1.35; income 1.22, 95% CI 1.03 to 1.44) and asthma with medication control (education 1.16, 95% CI 0.97 to 1.40; income 1.25, 95% CI 1.01 to 1.55). SIIs supported the lower risk for children with more highly educated mothers and those from higher-income households in most cohorts, with few exceptions.

CONCLUSIONS

Social inequalities by household income on the risk of ever asthma, wheezing/asthma attacks, and medication control for asthma were evident; the associations were attenuated for maternal education. These findings support the need for prevention policies to address the relatively high risks of respiratory morbidity in children in families with low socioeconomic status.

Progression of type 1 diabetes is associated with high levels of soluble PD-1 in islet autoantibody-positive children

AIMS/HYPOTHESIS

Type 1 diabetes is an autoimmune disorder that is characterised by destruction of pancreatic beta cells by autoreactive T lymphocytes. Although islet autoantibodies (AAb) are an indicator of disease progression, specific immune biomarkers that can be used as target molecules to halt development of type 1 diabetes have not been discovered. Soluble immune checkpoint molecules (sICM) play a pivotal role in counteracting excessive lymphocyte responses, but their role in type 1 diabetes is unexplored. In this longitudinal study, we measured sICM levels in AAb-positive (AAb+) children to identify molecules related to type 1 diabetes progression.

METHODS

We measured the levels of 14 sICM in the sera of AAb+ children (n=57) compared to those with recent-onset type 1 diabetes (n=79) and healthy children (n=44), obtained from two cohorts. AAb+ children were followed up and divided based on their progression to type 1 diabetes (AAbP) or not (AAbNP) (if they lost islet autoimmunity and did not develop disease in subsequent years). sICM were also measured in the sample taken at the visit closest to disease onset in AAbP children.

RESULTS

We found that AAb+ children had a distinct sICM profile compared with healthy children and those with recent-onset type 1 diabetes. In addition, AAb+ children who progressed to type 1 diabetes (AAbP) had higher sICM concentrations than non-progressors (AAbNP). Further, sICM levels decreased in AAbP children close to disease onset. Application of Cox regression models highlighted that high concentrations of soluble programmed cell death protein 1 (sPD-1) are associated with type 1 diabetes progression (HR 1.71; 95% CI 1.16, 2.51; p=0.007).

CONCLUSIONS/INTERPRETATION

This study reveals an sICM profile that is dysregulated during the preclinical stage of type 1 diabetes, and identifies sPD-1 as a pathophysiologically-relevant molecule that is associated with disease progression, offering a potential target for early interventions in autoimmune diabetes.

Increased Severity of Presentation Signs in Children with Newly Diagnosed Type 1 Diabetes during the COVID-19 Pandemic: A Tertiary Center Experience

INTRODUCTION

Diabetic ketoacidosis (DKA) is an important complication of type 1 diabetes mellitus (T1DM) which is worsened when the diagnosis of T1DM is delayed. The aim of this study was to evaluate the presentation patterns, severity, autoantibody status, and seasonal variability of newly diagnosed T1DM patients during the pandemic period of 2 years compared to those in the pre-pandemic period.

METHODS

In this single tertiary center retrospective cohort study, newly diagnosed T1DM patients were grouped as pre-pandemic and pandemic period. Age, gender, the month of diagnosis, hemoglobin A1c, venous blood gas parameters, duration of symptoms, glutamic-acid-decarboxylase-antibody (anti-GAD), islet-cell antibody (ICA), and insulin autoantibody levels were recorded. The data obtained were compared between the groups.

RESULTS

Number of patients presenting with DKA was significantly higher during the pandemic period (92 [65.7%] vs. 62 [40.8%] patients, p < 0.001). In terms of clinical severity of DKA, pH, and HCO3 levels were lower during the pandemic period (p < 0.001), while the number of patients presenting with severe DKA was significantly higher during the pandemic period (41 [44.6%] vs. 17 [27.4%] patients, p = 0.031). ICA positivity was significantly higher in patients admitted during the pandemic period (47 [36.4%] vs. 21 patients [16.9%], p < 0.001), especially in the second year of the pandemic (p < 0.001). Anti-GAD-ICA co-positivity was significantly higher in patients admitted during the pandemic period and also in second year of the pandemic (p < 0.001).

CONCLUSION

DKA rates increased in newly diagnosed T1DM cases during the pandemic. Despite the relaxation of bans, the second year of the pandemic also saw increased rates of DKA and severe DKA compared to the pre-pandemic period. The significantly increased ICA positivity in the pandemic may support the effects of COVID-19 on autoimmune T1DM.

Type 1 and Covid-19: Diagnosis, Clinical Care, and Health Outcomes during the Pandemic

The coronavirus disease 2019 (COVID-19) pandemic disrupted health care, creating challenges for people with diabetes and health care systems. Diabetes was recognized as a risk factor for severe disease early in the pandemic. Subsequently, risk factors specific for people with type 1 diabetes were identified, including age, hemoglobin A1c level, and lack of continuous glucose monitoring . Telemedicine, especially when accompanied by diabetes data, allowed effective remote care delivery. However, pre-existing racial disparities in access to diabetes technology persisted and were associated with worse outcomes. Events of the COVID-19 pandemic underscore the importance of continuing to develop flexible and more equitable health care delivery systems.

Psychological Alterations in Youths with Type I Diabetes: Associations with Salivary Cortisol Concentration

Background and Objectives: Type 1 diabetes mellitus (T1DM) is one of the most common chronic diseases in children and adolescents, and is associated with stress and other psychological alterations. This study aims to assess psychological and sleep disorders and health-related quality of life in young people with T1DM and to determine the relationship between these parameters and levels of salivary cortisol, a hormone widely associated with stress and several psychological symptoms. Materials and Methods: In our cross-sectional study performed in 60 Moroccan children and adolescents with T1DM, detailed psychological evaluations were performed to assess symptoms of anxiety, attention-deficit hyperactivity disorder (ADHD), sleep quality and diabetes-specific quality of life (using the RCMAS-2, ADHD rating scale, Pittsburgh scale and the DQoL scale, respectively), and cortisol concentration was measured from saliva samples taken mid-morning. Results: A total of 60 children and adolescents with T1DM were recruited. The mean age was 11.05 ± 0.35 (6-17). The mean salivary cortisol level in ng/mL was 4.7 ± 0.49 (0.7-20.2) and was significantly associated with an anxiety RCMAS2 score for the Worry subdomain and DQoL subdomain "Anxiety". Linear regression analysis showed that salivary cortisol was significantly higher in girls compared to boys (p = 0.004) (beta coefficient: 3.384 CI95%: 1.137-5.630) and with Hb1AC level as a continuous variable (p = 0.0001) (beta coefficient: 1.135 CI95%: 0.509-1.760). The other variables included in the model were not significant (p > 0.05). There was an association between salivary cortisol concentration with anxiety RCMAS2 score for Worry subdomain and QoL sub-domain "Anxiety". Still, a significant (p = 0.018) association emerged for anxiety RCMAS2 score Worry subdomain and QoL anxiety subdomain (p = 0.044). Conclusions: Children and adolescents with T1DM experienced significantly elevated symptoms of anxiety and sleep disturbances, particularly in girls, and frequent symptoms of ADHD, particularly in boys. Salivary cortisol concentration collected in the morning is associated with anxiety burden but not with other psychological alterations. Further studies are needed to clarify the associations between salivary cortisol concentration and anxiety in type 1 diabetes in order to propose the hormone as a biomarker for interventions aimed to reduce anxiety levels in these patients.

Association of Trauma With Long-Term Risk of Death and Immune-Mediated or Cancer Disease in Same-Sex Twins

Importance

Immediate consequences of trauma include a rapid and immense activation of the immune system, whereas long-term outcomes include premature death, physical disability, and reduced workability.

Objective

To investigate if moderate to severe trauma is associated with long-term increased risk of death or immune-mediated or cancer disease.

Design, Setting, and Participants

This registry-based, matched, co-twin control cohort study linked the Danish Twin Registry and the Danish National Patient Registry to identify twin pairs in which 1 twin had been exposed to severe trauma and the other twin had not from 1994 to 2018. The co-twin control design allowed for matching on genetic and environmental factors shared within twin pairs.

Exposure

Twin pairs were included if 1 twin had been exposed to moderate to severe trauma and the other twin had not (ie, co-twin). Only twin pairs where both twins were alive 6 months after the trauma event were included.

Main Outcome and Measure

Twin pairs were followed up from 6 months after trauma until 1 twin experienced the primary composite outcome of death or 1 of 24 predefined immune-mediated or cancer diseases or end of follow-up. Cox proportional hazards regression was used for intrapair analyses of the association between trauma and the primary outcome.

Results

A total of 3776 twin pairs were included, and 2290 (61%) were disease free prior to outcome analysis and were eligible for the analysis of the primary outcome. The median (IQR) age was 36.4 (25.7-50.2) years. The median (IQR) follow-up time was 8.6 (3.8-14.5) years. Overall, 1268 twin pairs (55%) reached the primary outcome; the twin exposed to trauma was first to experience the outcome in 724 pairs (32%), whereas the co-twin was first in 544 pairs (24%). The hazard ratio for reaching the composite outcome was 1.33 (95% CI, 1.19-1.49) for twins exposed to trauma. Analyses of death or immune-mediated or cancer disease as separate outcomes provided hazard ratios of 1.91 (95% CI, 1.68-2.18) and 1.28 (95% CI, 1.14-1.44), respectively.

Conclusion and Relevance

In this study, twins exposed to moderate to severe trauma had significantly increased risk of death or immune-mediated or cancer disease several years after trauma compared with their co-twins.

Incidence of Diabetes in Children and Adolescents During the COVID-19 Pandemic: A Systematic Review and Meta-Analysis

Importance

There are reports of increasing incidence of pediatric diabetes since the onset of the COVID-19 pandemic. Given the limitations of individual studies that examine this association, it is important to synthesize estimates of changes in incidence rates.

Objective

To compare the incidence rates of pediatric diabetes during and before the COVID-19 pandemic.

Data Sources

In this systematic review and meta-analysis, electronic databases, including Medline, Embase, the Cochrane database, Scopus, and Web of Science, and the gray literature were searched between January 1, 2020, and March 28, 2023, using subject headings and text word terms related to COVID-19, diabetes, and diabetic ketoacidosis (DKA).

Study Selection

Studies were independently assessed by 2 reviewers and included if they reported differences in incident diabetes cases during vs before the pandemic in youths younger than 19 years, had a minimum observation period of 12 months during and 12 months before the pandemic, and were published in English.

Data Extraction and Synthesis

From records that underwent full-text review, 2 reviewers independently abstracted data and assessed the risk of bias. The Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guideline was followed. Eligible studies were included in the meta-analysis and analyzed with a common and random-effects analysis. Studies not included in the meta-analysis were summarized descriptively.

Main Outcomes and Measures

The primary outcome was change in the incidence rate of pediatric diabetes during vs before the COVID-19 pandemic. The secondary outcome was change in the incidence rate of DKA among youths with new-onset diabetes during the pandemic.

Results

Forty-two studies including 102 984 incident diabetes cases were included in the systematic review. The meta-analysis of type 1 diabetes incidence rates included 17 studies of 38 149 youths and showed a higher incidence rate during the first year of the pandemic compared with the prepandemic period (incidence rate ratio [IRR], 1.14; 95% CI, 1.08-1.21). There was an increased incidence of diabetes during months 13 to 24 of the pandemic compared with the prepandemic period (IRR, 1.27; 95% CI, 1.18-1.37). Ten studies (23.8%) reported incident type 2 diabetes cases in both periods. These studies did not report incidence rates, so results were not pooled. Fifteen studies (35.7%) reported DKA incidence and found a higher rate during the pandemic compared with before the pandemic (IRR, 1.26; 95% CI, 1.17-1.36).

Conclusions and Relevance

This study found that incidence rates of type 1 diabetes and DKA at diabetes onset in children and adolescents were higher after the start of the COVID-19 pandemic than before the pandemic. Increased resources and support may be needed for the growing number of children and adolescents with diabetes. Future studies are needed to assess whether this trend persists and may help elucidate possible underlying mechanisms to explain temporal changes.

Low maternal education increases the risk of Type 1 Diabetes, but not other autoimmune diseases: a mediating role of childhood BMI and exposure to serious life events

The objective of this paper was to investigate if socioeconomic status (SES), measured by maternal education and household income, influenced the risk of developing autoimmune disease (Type 1 Diabetes, Celiac disease, Juvenile Idiopathic Arthritis, Crohn's disease, Ulcerative colitis, and autoimmune thyroid disease), or age at diagnosis, and to analyse pathways between SES and autoimmune disease. We used data from the All Babies in Southeast Sweden (ABIS) study, a population-based prospective birth cohort, which included children born 1997-1999. Diagnoses of autoimmune disease was collected from the Swedish National Patient Register Dec 2020. In 16,365 individuals, low maternal education, but not household income, was associated with increased risk of Type 1 Diabetes; middle education RR 1.54, 95% CI 1.06, 2.23; P 0.02, low education RR 1.81, 95% CI 1.04, 3.18; P 0.04. Maternal education and household income was not associated with any other autoimmune disease and did not influence the age at diagnosis. Part of the increased risk of Type 1 Diabetes by lower maternal education was mediated by the indirect pathway of higher BMI and higher risk of Serious Life Events (SLE) at 5 years of age. The risk of developing Type 1 Diabetes associated to low maternal education might be reduced by decreasing BMI and SLE during childhood.

Type 1 diabetes incidence in children and adolescents during the COVID-19 pandemic in Germany

AIMS/HYPOTHESIS

The aim of this study was to analyze the incidence of type 1 diabetes in children and adolescents (<20 years of age) during the COVID-19 pandemic (3/2020 to 12/2021) in Germany.

METHODS

The present study was based on the IQVIA longitudinal prescription database (LRx), All persons (age ≤ 20 years) with new insulin prescriptions from 2016 to 2021 (index date) were selected and stratified by age group. Weekly (age-specific) data were used to forecast the prescription incidence for the pandemic period based on pre-pandemic data and to explore the relationship between weekly reported age-specific COVID-19 incidences and type 1 diabetes incidence and rate ratios of observed vs. predicted diabetes incidence respectively.

RESULTS

During the pre-pandemic period, there was a stable higher insulin prescription incidence during the winter period and a lower insulin prescription incidence during summer. During the pandemic period, there was less seasonal variation in incidence related to the finding that the observed incidence during summer in 2002 and 2021 was 44 % and 65 %, higher, respectively, than the expected incidence based on pre-pandemic year. We did not find any cross-correlations between the COVID-19 incidence and the type 1 diabetes incidence for any age group. Likewise, there were no cross-correlations between the COVID-19 incidence and the incidence rate ratios of observed incidences to predicted incidences.

CONCLUSIONS/INTERPRETATION

During the COVID-19 pandemic, there was less seasonal variation in the incidence of type 1 diabetes (defined by new insulin prescriptions), with higher observed than expected incidences during summer. We found no evidence that the increase in type 1 diabetes incidence during the COVID-19 pandemic relates to direct effects of COVID-19 pandemic.

Comparative inequalities in child dental caries across four countries: Examination of international birth cohorts and implications for oral health policy

Child dental caries (i.e., cavities) are a major preventable health problem in most high-income countries. The aim of this study was to compare the extent of inequalities in child dental caries across four high-income countries alongside their child oral health policies. Coordinated analyses of data were conducted across four prospective population-based birth cohorts (Australia, n = 4085, born 2004; Québec, Canada, n = 1253, born 1997; Rotterdam, the Netherlands, n = 6690, born 2002; Southeast Sweden, n = 7445, born 1997), which enabled a high degree of harmonization. Risk ratios (adjusted) and slope indexes of inequality were estimated to quantify social gradients in child dental caries according to maternal education and household income. Children in the least advantaged quintile for income were at greater risk of caries, compared to the most advantaged quintile: Australia: AdjRR = 1.18, 95%CI = 1.04–1.34; Québec: AdjRR = 1.69, 95%CI = 1.36–2.10; Rotterdam: AdjRR = 1.67, 95%CI = 1.36–2.04; Southeast Sweden: AdjRR = 1.37, 95%CI = 1.10–1.71). There was a higher risk of caries for children of mothers with the lowest level of education, compared to the highest: Australia: AdjRR = 1.18, 95%CI = 1.01–1.38; Southeast Sweden: AdjRR = 2.31, 95%CI = 1.81–2.96; Rotterdam: AdjRR = 1.98, 95%CI = 1.71–2.30; Québec: AdjRR = 1.16, 95%CI = 0.98–1.37. The extent of inequalities varied in line with jurisdictional policies for provision of child oral health services and preventive public health measures. Clear gradients of social inequalities in child dental caries are evident in high-income countries. Policy related mechanisms may contribute to the differences in the extent of these inequalities. Lesser gradients in settings with combinations of universal dental coverage and/or fluoridation suggest these provisions may ameliorate inequalities through additional benefits for socio-economically disadvantaged groups of children.

Stress hyperglycemia, Diabetes mellitus and COVID-19 infection: The impact on newly diagnosed type 1 diabetes

Several recent studies have documented an increased incidence of newly diagnosed type 1 Diabetes (T1D) cases in children and adolescents during the COVID-19 pandemic and a more severe presentation at diabetes onset. In this descriptive study, we present the experience of the Diabetes Centre of the Division of Endocrinology, Diabetes, and Metabolism of the First Department of Pediatrics of the National and Kapodistrian University of Athens Medical School at “Aghia Sophia” Children’s Hospital in Athens, Greece, concerning new cases of T1D diagnosis during the COVID-19 pandemic (March 2020- December 2021). Patients who had already been diagnosed with T1D and needed hospitalization due to poor control during the pandemic have been excluded from this study. Eighty- three children and adolescents with a mean age of 8,5 ± 4.02 years were admitted to the hospital due to newly diagnosed T1D during this 22 months’ period in comparison to 34 new cases in the previous year. All patients admitted during the pandemic with a new diagnosis of T1D, presented in their majority with DKA (Ph: 7.2) representing an increase of new severe cases in comparison to previous years (Ph 7.2 versus 7.3, p value: 0.021, in the previous year), [p-value: 0.027]. 49 cases presented with DKA, of which 24 were characterized moderate and 14 severe DKA (28.9% and 16,9%, respectively), while 5 patients newly diagnosed, needed to be admitted to the ICU to recover from severe acidosis. Whether a previous COVID- 19 infection could have been the triggering factor is not supported by the SARS-Cov2 specific antibodies analysis in our cohort of patients. As far as HbA1c is concerned there was no statistically significant difference between the pre COVID-19 year and the years of the pandemic (11.6% versus 11.9%, p- value: 0.461). Triglycerides values were significantly higher in patients with new onset T1D during COVID-19 years compared to those before the pandemic (p value= 0.032). Additionally, there is a statistically significant correlation between Ph and Triglycerides for the whole period 2020-2021 (p-value&lt;0.001), while this correlation is not significant for the year 2019. More large- scale studies are required to confirm these observations.

Urinary tract infection in patients with diabetes mellitus and the role of parental genetics in the emergence of the disease

This study aimed to assess the role of paternal genetics in the development of diabetic mellitus (DM) and determine the impact of DM on the urinary system by investigating the percentage of patients with urinary tract infection (UTI). The study included 100 people with DM; their ages ranged from 5 to 83 years. The DM and blood sugar levels were diagnosed clinically and at a laboratory in Al-Zahra Teaching Hospital and the outpatient clinics. The age, gender, and causes of DM and the family history of diabetes were reported. Isolation and identification of bacterial species were made depending on culture media and biochemical tests. The average age of patients was 47.7±5.5, and most of them were female (67%). The incidence of DM increased with age, and the main cause of DM was likely to be a genetic predisposition (family history), where 32% of patients appeared to have a positive family history and the presence of DM in both parents or only the mother had a significant role in increasing the genetic predisposition of developing DM. Among the non-genetic causes of DM, the most common was exposure to sudden psychological or nervous shock (41%). Obesity also had an important role in the development of diabetes, and also pregnancy and smoking. Moreover, 66% of patients with type 2 DM and all with type 1 DM suffered from UTIs. The main causative agents were E. coli (60%) and Proteus spp. (13%). The majority of patients suffering from UTIs (73%) were females. In conclusion, type 2 DM is the most common, especially in females, and increases with age. The main cause of DM was family genetic predisposition and sudden shocks. The current study also showed that most diabetic patients suffered from UTIs, especially females, and the main causes of UTI inflammation are E. coli isolates.

Incidence of Type 1 Diabetes in Children and Adolescents During the COVID-19 Pandemic in Germany: Results From the DPV Registry

OBJECTIVE

The aim of this study was to investigate the incidence of type 1 diabetes in children and adolescents during the coronavirus disease 2019 (COVID-19) pandemic in Germany compared with previous years.

RESEARCH DESIGN AND METHODS

Based on data from the multicenter German Diabetes Prospective Follow-up Registry, we analyzed the incidence of type 1 diabetes per 100,000 patient-years in children and adolescents from 1 January 2020 through 30 June 2021. Using Poisson regression models, expected incidences for 2020/21 were estimated based on the data from 2011 to 2019 and compared with observed incidences in 2020/21 by estimating incidence rate ratios (IRRs) with 95% CIs.

RESULTS

From 1 January 2020 to 30 June 2021, 5,162 children and adolescents with new-onset type 1 diabetes in Germany were registered. The observed incidence in 2020/21 was significantly higher than the expected incidence (24.4 [95% CI 23.6-25.2] vs. 21.2 [20.5-21.9]; IRR 1.15 [1.10-1.20]; P < 0.001). IRRs were significantly elevated in June 2020 (IRR 1.43 [1.07-1.90]; P = 0.003), July 2020 (IRR 1.48 [1.12-1.96]; P < 0.001), March 2021 (IRR 1.29 [1.01-1.65]; P = 0.028), and June 2021 (IRR 1.39 [1.04-1.85]; P = 0.010).

CONCLUSIONS

A significant increase in the incidence of type 1 diabetes in children was observed during the COVID-19 pandemic, with a delay in the peak incidence of type 1 diabetes by ∼3 months after the peak COVID-19 incidence and also after pandemic containment measures. The underlying causes are yet unknown. However, indirect rather than direct effects of the pandemic are more likely to be the cause.

Household income and maternal education in early childhood and activity-limiting chronic health conditions in late childhood: findings from birth cohort studies from six countries

BACKGROUND

We examined absolute and relative relationships between household income and maternal education during early childhood (<5 years) with activity-limiting chronic health conditions (ALCHC) during later childhood in six longitudinal, prospective cohorts from high-income countries (UK, Australia, Canada, Sweden, Netherlands, USA).

METHODS

Relative inequality (risk ratios, RR) and absolute inequality (Slope Index of Inequality) were estimated for ALCHC during later childhood by maternal education categories and household income quintiles in early childhood. Estimates were adjusted for mother ethnicity, maternal age at birth, child sex and multiple births, and were pooled using meta-regression.

RESULTS

Pooled estimates, with over 42 000 children, demonstrated social gradients in ALCHC for high maternal education versus low (RR 1.54, 95% CI 1.28 to 1.85) and middle education (RR 1.24, 95% CI 1.11 to 1.38); as well as for high household income versus lowest (RR 1.90, 95% CI 1.66 to 2.18) and middle quintiles (RR 1.34, 95% CI 1.17 to 1.54). Absolute inequality showed decreasing ALCHC in all cohorts from low to high education (range: -2.85% Sweden, -13.36% Canada) and income (range: -1.8% Sweden, -19.35% Netherlands).

CONCLUSION

We found graded relative risk of ALCHC during later childhood by maternal education and household income during early childhood in all cohorts. Absolute differences in ALCHC were consistently observed between the highest and lowest maternal education and household income levels across cohort populations. Our results support a potential role for generous, universal financial and childcare policies for families during early childhood in reducing the prevalence of activity limiting chronic conditions in later childhood.

Prenatal and early life factors and type 1 diabetes

BACKGROUND

The prevalence of type 1 diabetes is increasing worldwide, suggesting that unknown environmental factors are becoming increasingly important in its pathogenesis.

AIM

The aim of the study was to investigate the possible role of a number of prenatal and perinatal factors in the aetiology of type 1 diabetes.

METHODS

Mothers of patients diagnosed with type 1 diabetes (cases) and mothers of children born on the same day and of the same sex as type 1 diabetes patients (controls) were interviewed on a number of prenatal and perinatal factors of interest.

RESULTS

Hand washing prior to eating, frequency of bathing and total stress score were found to be positively associated with the development of type 1 diabetes on univariate analyses. Hand-washing prior to eating and frequency of house cleaning were independently associated with an increased risk of type 1 diabetes, whilst getting dirty was associated with a reduced risk in multivariate analyses. There was no association of type 1 diabetes to removing of outdoor shoes indoors or to the age of first attendance to school or pre-school. There were also no significant associations to parental smoking, parental age, birth order, infant feeding, antibiotic use, mode of delivery or birth weight.

CONCLUSION

Our data suggest that factors that affect the skin or gut microbiome might be more important than infections or factors affecting the microbiome at other sites.

Breastfeeding, nutrition and type 1 diabetes: a case-control study in Izmir, Turkey

Background

The relationship between infant breastfeeding and type 1 diabetes mellitus (DM) is unclear but it has been suggested that there may be a link between many environmental factors, including dietary antigens affecting diabetes epidemiology.

The main objective of this study is to investigate nutritional risk factors, especially breastfeeding early in life that may be associated with the development of type 1 DM and to determine the relationship these factors have with the disease.

Methods

This research is a case-control study and was carried out in Ege University Children’s Hospital in İzmir, Turkey between 13 January 2020 and 5 March 2020. A total of 246 children aged between 4 and 14 years were included in the study. The case group consisted of patients diagnosed with type 1 DM followed-up by Ege University Children’s Hospital’s Endocrinology Unit and the control group included non-diabetic children attending the same hospital’s General Pediatric Outpatient Clinic. A structured questionnaire was created by the researchers after reviewing the literature related to nutritional and other risk factors for type 1 DM. The questionnaire was administered by interviewing the parents and it was related to the child, mother and family of the child. In this study, breastfeeding duration was defined as the total duration of breastfeeding and exclusive breastfeeding meant that the child received only breast milk from the mother.

Results

The mean age at diagnosis was 6.30 ± 4.03 years for cases and 7.48 ± 2.56 years for controls. We found that each monthly increase in exclusive breastfeeding duration provided a 0.83-fold (95% CI 0.72, 0.96) decrease in the risk of type 1 DM. Introduction of cereals in the diet at the sixth month or earlier was associated with a 2.58-fold (95% CI 1.29, 5.16) increased risk.

Conclusions

Determining the contribution of exclusive breastfeeding to the disease is important in establishing preventive policies. A longer duration of exclusive breastfeeding may be an important role in preventing the disease. This free intervention that truly works will be cost-effective. Future studies are needed to clarify the role of both exclusive and non-exclusive breastfeeding on the development of type 1 DM.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-022-00470-z.

Social gradients in ADHD by household income and maternal education exposure during early childhood: Findings from birth cohort studies across six countries

OBJECTIVE

This study aimed to examine social gradients in ADHD during late childhood (age 9-11 years) using absolute and relative relationships with socioeconomic status exposure (household income, maternal education) during early childhood (<5 years) in seven cohorts from six industrialised countries (UK, Australia, Canada, The Netherlands, USA, Sweden).

METHODS

Secondary analyses were conducted for each birth cohort. Risk ratios, pooled risk estimates, and absolute inequality, measured by the Slope Index of Inequality (SII), were estimated to quantify social gradients in ADHD during late childhood by household income and maternal education measured during early childhood. Estimates were adjusted for child sex, mother age at birth, mother ethnicity, and multiple births.

FINDINGS

All cohorts demonstrated social gradients by household income and maternal education in early childhood, except for maternal education in Quebec. Pooled risk estimates, relating to 44,925 children, yielded expected gradients (income: low 1.83(CI 1.38,2.41), middle 1.42(1.13,1.79), high (reference); maternal education: low 2.13(1.39,3.25), middle 1.42(1.13,1.79)). Estimates of absolute inequality using SII showed that the largest differences in ADHD prevalence between the highest and lowest levels of maternal education were observed in Australia (4% lower) and Sweden (3% lower); for household income, the largest differences were observed in Quebec (6% lower) and Canada (all provinces: 5% lower).

CONCLUSION

Findings indicate that children in families with high household income or maternal education are less likely to have ADHD at age 9-11. Absolute inequality, in combination with relative inequality, provides a more complete account of the socioeconomic status and ADHD relationship in different high-income countries. While the study design precludes causal inference, the linear relation between early childhood social circumstances and later ADHD suggests a potential role for policies that promote high levels of education, especially among women, and adequate levels of household income over children's early years in reducing risk of later ADHD.

War Psychiatry: Identifying and Managing the Neuropsychiatric Consequences of Armed Conflicts

War refugees and veterans have been known to frequently develop neuropsychiatric conditions including depression, post-traumatic stress disorder (PTSD), and anxiety disorders that tend to leave a long-lasting scar and impact their emotional response system. The shear stress, trauma, and mental breakdown from overnight displacement, family separation, and killing of friends and families cannot be described enough. Victims often require years of mental health support as they struggle with sleep difficulties, recurring memories, anxiety, grief, and anger. Everyone develops their coping mechanism which can involve dependence and long-term addiction to alcohol, drugs, violence, or gambling. The high prevalence of mental health disorders during and after the war indicates an undeniable necessity for screening those in need of treatment. For medical health professionals, it is crucial to identify such vulnerable groups who are prone to developing neuropsychiatric morbidities and associated risk factors. It is pivotal to develop and deploy effective and affordable multi-sectoral collaborative care models and therapy, which primarily depends upon family and primary care physicians in the conflict zones. Herein, we provide a brief overview regarding the identification and management of vulnerable populations, alongside discussing the challenges and possible solutions to the same.

Environmental Triggering of Type 1 Diabetes Autoimmunity

Type 1 diabetes (T1D) is a chronic autoimmune disease in which pancreatic islet β cells are destroyed by immune cells, ultimately leading to overt diabetes. The progressive increase in T1D incidence over the years points to the role of environmental factors in triggering or accelerating the disease process which develops on a highly multigenic susceptibility background. Evidence that environmental factors induce T1D has mostly been obtained in animal models. In the human, associations between viruses, dietary habits or changes in the microbiota and the development of islet cell autoantibodies or overt diabetes have been reported. So far, prediction of T1D development is mostly based on autoantibody detection. Future work should focus on identifying a causality between the different environmental risk factors and T1D development to improve prediction scores. This should allow developing preventive strategies to limit the T1D burden in the future.

Curcumin plays a local anti-inflammatory and antioxidant role via the HMGB1/TLR4/NF-ΚB pathway in rat masseter muscle under psychological stress

BACKGROUND AND OBJECTIVE

Psychological stress causes structural and metabolic dysfunction of masseter muscles. The anti-inflammatory and anti-oxidative polyphenol curcumin plays a local antioxidant role in rat masseter muscles under psychological stress by an as-yet-unknown mechanism. The present study aimed to assess curcumin anti-inflammatory and anti-oxidative effects on masseter muscle and its possible molecular mechanisms.

METHODS

We constructed a rat model of chronic unpredictable moderate stress (CUMS). Psychological stress was assessed by determining the levels of adrenocorticotropic hormone (ACTH) and cortisol in serum. Enzyme-linked immunosorbent assays measured inflammatory cytokines and markers of oxidative stress in masseter muscles. Levels of high-mobility group box 1 (HMGB1), interleukin (IL)-1β, IL-6 and tumour necrosis factor-alpha (TNF-α) were determined using quantitative PCR analyses and immunofluorescent staining. Toll-like receptor 4 (TLR4) and nuclear factor kappa B (NF-κB) activation were examined using western blotting.

RESULTS

The CUMS group showed increased serum cortisol and ACTH levels. Pathological changes in the ultrastructure, oxidative stress and inflammatory cytokines in the masseter muscles were also observed. Curcumin treatment (50, 100 mg/kg) ameliorated these changes significantly by varying degrees. Mechanistically, increased levels of phosphorylated NF-κB, toll-like receptor 4 and HMGB1 were observed, which were also ameliorated by curcumin treatment.

CONCLUSION

Curcumin can reduce local pathological changes, levels of oxidative stress and inflammatory factors in masseter muscles. Psychological stress activates HMGB1 expression and increases the expression of downstream TLR4 and p-NF-κB, which could be reduced by curcumin. Thus, curcumin might exert anti-inflammatory and antioxidant effects in masseter muscles via the HMGB1/TLR4/NF-κB pathway.

Increasing plasma glucose before the development of type 1 diabetes-the TRIGR study

OBJECTIVE

The β-cell stress hypothesis suggests that increased insulin demand contributes to the development of type 1 diabetes. In the TRIGR trial we set out to assess the profile of plasma glucose and HbA1c before the diagnosis of clinical diabetes compared to nondiabetic children.

RESEARCH DESIGN AND METHODS

A cohort of children (N = 2159) with an affected first-degree relative and increased HLA risk were recruited 2002-2007 and followed until 2017. To study the relationship between plasma glucose/HbA1c and the development of autoantibodies or clinical disease Kaplan-Meir curves were developed. Mixed models were constructed for plasma glucose and HbA1c separately.

RESULTS

A family history of type 2 diabetes was related to an increase in plasma glucose (p < 0.001). An increase in glucose from the previous sample predicted clinical diabetes (p < 0.001) but not autoantibodies. An increase of HbA1c of 20% or 30% from the previous sample predicted the development of any autoantibody (p < 0.003 resp <0.001) and the development of diabetes (p < 0.002 resp <0.001. Participants without autoantibodies had lower HbA1c (mean 5.18%, STD 0.24; mean 33.08 mmol/mol, STD 2.85) than those who progressed to clinical disease (5.31%, 0.42; 34.46 mmol/mol, 4.68; p < 0.001) but higher than those who developed any autoantibody (5.10%, 0.30; 32.21 mmol/mol, 3.49; p < 0.001), or multiple autoantibodies (5.11%, 0.35; 32.26 mmol/mol, 3.92; p < 0.003).

CONCLUSIONS

A pronounced increase in plasma glucose and HbA1c precedes development of clinical diabetes, while the association between plasma glucose or HbA1c and development of autoantibodies is complex. Increased insulin demand may contribute to development of type 1 diabetes.

Breastfeeding and cortisol in hair in children

Background

One of the most important protective health factors for children is breast-feeding, but the mechanisms for this effect are not fully elucidated. Our objective was to assess if the duration of breastfeeding influences cortisol in hair, used as a biomarker for stress in children still at school-age.

Methods

ABIS (All Babies in Southeast Sweden) is a prospective population-based child cohort study of 17,055 children born Oct 1st1997- Oct 1st 1999, with the aim to study development of immune-mediated diseases. Questionnaires were answered at birth and then at regular follow-ups, and biological samples were collected. As a biomarker of stress, we measured the child’s cortisol in hair collected at 8 years of age, those randomly selected N = 126 children among those with enough hair samples for analyses of hair at 8 years of age. Duration of breastfeeding had been registered as well as psycho-social factors related to breastfeeding and/or stress.

Results

There was a negative correlation (r = − 0.23, p = 0.01) between total duration of breastfeeding and hair cortisol levels at 8 years of age. In a multivariate analysis this association persisted (p = 0.01) even when adjusted for other potential intervening factors like age of mother at delivery and early psychosocial vulnerability in the family, an index based on 11 factors (Multivariate model: df = 5, adj R² = 0.15, F = 5.38, p < 0.01).

Conclusion

Our results show that longer breastfeeding is associated with lower cortisol levels in the child many years later. These associations should be more elaborated in further studies, and these findings also give some implications for public health. Mothers should be encouraged to breastfeed their children also in the modern society, since breastfeeding promotes health in the child. This information could be given via the obstetric departments and later at the well-baby clinics.

Infections and antibiotics during fetal life and childhood and their relationship to juvenile idiopathic arthritis: a prospective cohort study

BACKGROUND

The aetiology of juvenile idiopathic arthritis (JIA) is poorly understood. It has been shown that use of antibiotics is associated with JIA. However, whether the association is due to increased occurrence of infection in these individuals is unknown. The purpose of this investigation was to measure the association between number of infections and use of antibiotics during childhood with development of JIA.

METHODS

In ABIS (All Babies in Southeast Sweden) a population-based prospective birth cohort of 17,055 children, data were collected on infections and antibiotic exposure during pregnancy and childhood. 102 individuals with JIA were identified. Multivariable logistic regression analyses were performed, adjusting for confounding factors.

RESULTS

Exposure to antibiotics during the periods 1-12 months, 1-3 years and 5-8 years was significantly associated with increased risk for JIA. The odds of developing JIA were three times higher in those exposed to antibiotics during the first 3 years of life compared with those not exposed (aOR 3.17; 95% CI 1.11-9.03, p = 0.031), and more than twice as high in those exposed to antibiotics during the first 5 years of life compared with those not exposed (aOR 2.18; 95% CI 1.36-3.50, p = 0.001). The odds of developing JIA were 78% higher in those exposed to antibiotics during the first 8 years of life compared with those not exposed (aOR 1.78; 95% CI 1.15-2.73, p = 0.009). Occurrence of infection during fetal life or childhood showed no significant association with the risk of developing JIA, after confounder adjustment. The cumulative number of courses of antibiotics was significantly higher during childhood for the individuals who developed JIA (p < 0.001). Penicillins were more frequently used than non-penicillins, but both had an equal effect on the risk of developing JIA.

CONCLUSIONS

Exposure to antibiotics early in life is associated with later onset of JIA in a large birth cohort from the general population. The relationship was dose dependent. These results suggest that further, more restrictive, antibiotic policies during the first years of life would be advisable.

Psychosocial factors affecting the etiology and management of type 1 diabetes mellitus: A narrative review

Type 1 diabetes (T1D) is one of the most common chronic diseases in children and adolescents worldwide. Its etiopathogenesis results from the interplay of genetic and environmental variables. Among the latter, psychological stress has been implicated in disease onset as well as disease management. Various studies, including large population-based studies, have highlighted the role of stressful life events in the etiopathogenesis of T1D. In this article, we also emphasize the importance of attachment in the early child-caregiver relationship, which can be seen as a measure of the quality of the relationship and is crucial for stress and emotional regulation. It serves as a model for all subsequent relationships in one's life. We summarize some of the few studies performed in the field of attachment and T1D etiopathogenesis or management. T1D management demands a lifelong therapeutic regimen to prevent acute and chronic complications. In addition to psychological stress, psychological factors such as family functioning, developmental adjustment, autonomy, mental health problems and other factors have been found to relate to metabolic control. Psychological factors need to be understood not as a single directional causality-based principle but as a dynamic bi- or multidirectional system that is affected by the normal developmental transitions of childhood and adolescence.

The Multifactorial Progression from the Islet Autoimmunity to Type 1 Diabetes in Children

Type 1 Diabetes (T1D) results from autoimmune destruction of insulin producing pancreatic ß-cells. This disease, with a peak incidence in childhood, causes the lifelong need for insulin injections and necessitates careful monitoring of blood glucose levels. However, despite the current insulin therapies, it still shortens life expectancy due to complications affecting multiple organs. Recently, the incidence of T1D in childhood has increased by 3-5% per year in most developed Western countries. The heterogeneity of the disease process is supported by the findings of follow-up studies started early in infancy. The development of T1D is usually preceded by the appearance of autoantibodies targeted against antigens expressed in the pancreatic islets. The risk of T1D increases significantly with an increasing number of positive autoantibodies. The order of autoantibody appearance affects the disease risk. Genetic susceptibility, mainly defined by the human leukocyte antigen (HLA) class II gene region and environmental factors, is important in the development of islet autoimmunity and T1D. Environmental factors, mainly those linked to the changes in the gut microbiome as well as several pathogens, especially viruses, and diet are key modulators of T1D. The aim of this paper is to expand the understanding of the aetiology and pathogenesis of T1D in childhood by detailed description and comparison of factors affecting the progression from the islet autoimmunity to T1D in children.

Carer's Attachment Anxiety, Stressful Life-Events and the Risk of Childhood-Onset Type 1 Diabetes

Background/Objective: Type 1 diabetes (T1D) is among the most common chronic diseases in children/adolescents, and the incidence continues to rise worldwide. Different environmental factors have been evaluated in the etiology. In the present study, we investigated the role of attachment examining whether insecure attachment to carers or carers' own attachment insecurity was related to a higher risk of T1D in children. Methods: We included 101 children with T1D (mean age 11.8 years), 106 healthy controls (11.6 years), and one of their carers. We assessed children's attachment using the Child Attachment Interview and carers' attachment using the Relationship Structures Questionnaire. We constructed binary multinomial logistic regression models using attachment to mothers, carers' attachment representations, and stressful life-events as T1D predictors. Results: Higher carer attachment anxiety was associated with the child's T1D diagnosis (p < 0.05; R 2 = 0.0613) while security of attachment to mothers showed no significant association. When mothers' education was included in the model, both attachment anxiety in higher educated mothers and stressful life events showed a significant association with the child's T1D (p < 0.001; R 2 = 0.293). Conclusions: Our findings suggest that higher attachment-related anxiety in carers with high education and stressful life events are associated with T1D in children.

Diagnosis and treatment of type 1 diabetes at the dawn of the personalized medicine era

Type 1 diabetes affects millions of people globally and requires careful management to avoid serious long-term complications, including heart and kidney disease, stroke, and loss of sight. The type 1 diabetes patient cohort is highly heterogeneous, with individuals presenting with disease at different stages and severities, arising from distinct etiologies, and overlaying varied genetic backgrounds. At present, the “one-size-fits-all” treatment for type 1 diabetes is exogenic insulin substitution therapy, but this approach fails to achieve optimal blood glucose control in many individuals. With advances in our understanding of early-stage diabetes development, diabetes stratification, and the role of genetics, type 1 diabetes is a promising candidate for a personalized medicine approach, which aims to apply “the right therapy at the right time, to the right patient”. In the case of type 1 diabetes, great efforts are now being focused on risk stratification for diabetes development to enable pre-clinical detection, and the application of treatments such as gene therapy, to prevent pancreatic destruction in a sub-set of patients. Alongside this, breakthroughs in stem cell therapies hold great promise for the regeneration of pancreatic tissues in some individuals. Here we review the recent initiatives in the field of personalized medicine for type 1 diabetes, including the latest discoveries in stem cell and gene therapy for the disease, and current obstacles that must be overcome before the dream of personalized medicine for all type 1 diabetes patients can be realized.

Trajectories of Childhood Adversity and Type 1 Diabetes: A Nationwide Study of One Million Children

OBJECTIVE

Experiencing adversities in childhood may increase the risk of type 1 diabetes through hyperactivation of the stress response system, but the empirical evidence is conflicting. We aim to describe the age-specific incidence of type 1 diabetes for males and females separately in five predefined groups covering the most common trajectories of adversity among Danish children.

RESEARCH DESIGN AND METHODS

We included all 1,081,993 children without parental type 1 diabetes born in Denmark from 1980 to 1998. We used register data to estimate age-specific incidence rates of type 1 diabetes in five trajectory groups of adversity characterized by 1) low adversity, 2) early life material deprivation, 3) persistent material deprivation, 4) loss or threat of loss in the family, and 5) cumulative high adversity. All analyses were stratified by sex.

RESULTS

In total, 5,619 people developed type 1 diabetes before 2016. We found only minor differences when comparing the incidence rates of type 1 diabetes between the trajectory groups. The only clear exceptions were in the high versus low adversity group, in which males had a higher incidence of type 1 diabetes in childhood (<11 years [incidence rate ratio (IRR) 1.78 (95% CI 1.31-2.42)]) and females had a higher incidence in early adulthood (≥16 years [IRR 2.19 (95% CI 1.57-3.07)]).

CONCLUSIONS

Childhood adversities were generally not associated with age-specific incidence of type 1 diabetes except among those exposed to a very high and increasing annual rate of childhood adversities. Differences between highly exposed males and females seem to depend on age at onset of type 1 diabetes.

First-appearing islet autoantibodies for type 1 diabetes in young children: maternal life events during pregnancy and the child's genetic risk

AIMS/HYPOTHESIS

Psychological stress has long been considered a possible trigger of type 1 diabetes, although prospective studies examining the link between psychological stress or life events during pregnancy and the child's type 1 diabetes risk are rare. The objective of this study was to examine the association between life events during pregnancy and first-appearing islet autoantibodies (IA) in young children, conditioned by the child's type 1 diabetes-related genetic risk.

METHODS

The IA status of 7317 genetically at-risk The Environmental Determinants of Diabetes in the Young (TEDDY) participants was assessed every 3 months from 3 months to 4 years, and bi-annually thereafter. Reports of major life events during pregnancy were collected at study inception when the child was 3 months of age and placed into one of six categories. Life events during pregnancy were examined for association with first-appearing insulin (IAA) (N = 222) or GAD (GADA) (N = 209) autoantibodies in the child until 6 years of age using proportional hazard models. Relative excess risk due to interaction (RERI) by the child's HLA-DR and SNP profile was estimated.

RESULTS

Overall, 65% of mothers reported a life event during pregnancy; disease/injury (25%), serious interpersonal (28%) and job-related (25%) life events were most common. The association of life events during pregnancy differed between IAA and GADA as the first-appearing autoantibody. Serious interpersonal life events correlated with increased risk of GADA-first only in HLA-DR3 children with the BACH2-T allele (HR 2.28, p < 0.0001), an additive interaction (RERI 1.87, p = 0.0004). Job-related life events were also associated with increased risk of GADA-first among HLA-DR3/4 children (HR 1.53, p = 0.04) independent of serious interpersonal life events (HR 1.90, p = 0.002), an additive interaction (RERI 1.19, p = 0.004). Job-related life events correlated with reduced risk of IAA-first (HR 0.55, p = 0.004), particularly in children with the BTNL2-GG allele (HR 0.48; 95% CI 0.31, 0.76).

CONCLUSIONS/INTERPRETATION

Specific life events during pregnancy are differentially related to IAA vs GADA as first-appearing IA and interact with different HLA and non-HLA genetic factors, supporting the concept of different endotypes underlying type 1 diabetes. However, the mechanisms underlying these associations remain to be discovered. Life events may be markers for other yet-to-be-identified factors important to the development of first-appearing IA.

Integrative analyses of TEDDY Omics data reveal lipid metabolism abnormalities, increased intracellular ROS and heightened inflammation prior to autoimmunity for type 1 diabetes

BACKGROUND

The Environmental Determinants of Diabetes in the Young (TEDDY) is a prospective birth cohort designed to study type 1 diabetes (T1D) by following children with high genetic risk. An integrative multi-omics approach was used to evaluate islet autoimmunity etiology, identify disease biomarkers, and understand progression over time.

RESULTS

We identify a multi-omics signature that was predictive of islet autoimmunity (IA) as early as 1 year before seroconversion. At this time, abnormalities in lipid metabolism, decreased capacity for nutrient absorption, and intracellular ROS accumulation are detected in children progressing towards IA. Additionally, extracellular matrix remodeling, inflammation, cytotoxicity, angiogenesis, and increased activity of antigen-presenting cells are observed, which may contribute to beta cell destruction. Our results indicate that altered molecular homeostasis is present in IA-developing children months before the actual detection of islet autoantibodies, which opens an interesting window of opportunity for therapeutic intervention.

CONCLUSIONS

The approach employed herein for assessment of the TEDDY cohort showcases the utilization of multi-omics data for the modeling of complex, multifactorial diseases, like T1D.

Accumulation of childhood adversities and type 1 diabetes risk: a register-based cohort study of all children born in Denmark between 1980 and 2015

BACKGROUND

Previous studies have indicated an association between childhood adversities and type 1 diabetes but have been underpowered and limited by selection. We aim to quantify the effect of accumulation of childhood adversities on type 1 diabetes risk, and to assess whether the effect differs between males and females in a large and unselected population sample.

METHODS

We used register-based data covering all children born in Denmark between 1980 and 2015, totalling >2 million children. We specified a multi-state model to quantify the effect of accumulation of childhood adversities on type 1 diabetes risk. The effects of specific childhood adversities on type 1 diabetes were estimated using proportional hazards models.

RESULTS

Accumulation of childhood adversities had a quantitatively small effect on type 1 diabetes risk among females [adjusted hazard ratio (HR) per adversity increase: 1.07; 95% confidence interval (CI): 1.02-1.11], but not among males (adjusted HR per adversity increase: 0.99; 95% CI: 0.97-1.03). Females exposed to extreme numbers (7+) of adversities had two times higher risk of type 1 diabetes compared with unexposed females (adjusted HR: 2.06; 95% CI: 1.10-3.86).

CONCLUSIONS

In an unselected total population sample, we generally find no or negligible effects of childhood adversities on type 1 diabetes risk, which may be reassuring to persons with type 1 diabetes who are concerned that personal trauma contributed to their disease. There is a very small group of females exposed to a high degree of adversity who may have a higher risk of type 1 diabetes and this group needs further attention.

What do parents believe are the causes of their Type 1 diabetic child's condition?

Purpose

This paper aims to investigate parents' beliefs about the causes of their child's Type 1 diabetes to understand if this affects the way diagnosis is processed and if this impacts on sibling parenting.

Design/methodology/approach

Online, semi-structured qualitative interviews with nine parents of children with Type 1 diabetes who have at least one non-diabetic child. The results were analysed using interpretative phenomenological analysis (IPA).

Findings

Two interlinked themes were identified: “What ifs”: parents postulated underlying genetic reasons for their child's diabetes and had working theories about the triggers of diabetes that included stress, infection, vaccination or a virus. Developing a personal aetiology of their child's condition allowed some a feeling of control, while others focused on practical ways to manage diabetes. “Having something to blame”: narratives dwelt on the relationship between beliefs about causes and self-blame. Some believed that acting on an identified trigger reduced personal guilt.

Research limitations/implications

Although internet access is widespread in the UK, a limitation of this research is that it excluded those without internet access.

Practical implications

The findings of this research may provide greater depth and a more holistic perspective to the health promoter to better support parents of Type 1 diabetics.

Social implications

The analysis of illness narratives that this research provides may offer a greater understanding of the social context in which health and illness develop. This research found some examples of parental confidence about the causes and triggers of their child's diabetes being positively associated with a sense of control. This might indicate the value of a more comprehensive larger-scale study to establish whether parents who are supported to develop a personalised conception of the aetiology of their child's diabetes develop a greater sense of coherence and well-being regarding their child's condition.

Originality/value

There is very limited literature focusing on the beliefs of sufferers and their families about Type 1 diabetes causality. Of that which does exist, some research is heterogenous in its sampling of Types 1 and 2 diabetes sufferers. This study offers a rare, focused insight into the beliefs of parents about the background causes and more proximal triggers of their child's Type 1 diabetes.

The Challenges of Identifying Environmental Determinants of Type 1 Diabetes: In Search of the Holy Grail

Type 1 diabetes is the result of autoimmune-mediated destruction and inflammation of the insulin-producing β-cells of the pancreas. The excess morbidity and mortality from its complications coupled with its increasing incidence emphasize the importance to better understand the etiology of this condition. It has a strong genetic component, but a genetic predisposition is not the sole contributor to disease development as only 30% to 50% of identical twins both develop the disease. In addition, there are multiple lines of evidence to support that environmental factors contribute to the pathogenesis of type 1 diabetes. Environmental risk factors that have been proposed include infections, dietary factors, air pollution, vaccines, location of residence, childhood obesity, family environment and stress. Researchers have conducted many observational studies to identify and characterize these potential environmental factors, but findings have been inconsistent or inconclusive. Many studies have had inherent methodological issues in recruitment, participation, defining cases and exposures, and/or data analysis which may limit the interpretability of findings. Identifying and addressing these limitations may allow for greatly needed advances in our understanding of type 1 diabetes. As such, the purpose of this article is to review and discuss the limitations of observational studies that aim to determine environmental risk factors for type 1 diabetes and propose recommendations to overcome them.

Neighborhood Deprivation and Risks of Autoimmune Disorders: A National Cohort Study in Sweden

Background: No study to date, as far as we know, has analyzed the potential effect of neighborhood-level deprivation on autoimmune disorders (ADs), when adjusted for individual-level characteristics. Methods: A total of 5.4 million individuals from 8363 neighborhoods, comprising the whole Swedish population (ages 25–74 years), were followed for the period 1 January 2000, until admission due to diagnosis of ADs during the period of the study, or the conclusion of the study (31 December 2010). We used a neighborhood deprivation index, constructed from variables such as low education, low income, unemployment, and social welfare assistance, to assess the level of neighborhood deprivation. Multilevel logistic regression was used in the analysis with individual level characteristics at the first level and level of neighborhood deprivation at the second level. Results: A significant association between level of neighborhood deprivation and ADs was found. The crude odds were 1.32 (95% confidence interval 1.27–1.36) for those residing in the high-deprived neighborhoods compared to those living in low-deprivation neighborhoods. In the full model, where individual level characteristics were taken into account, the odds of ADs were 1.18 (1.14–1.22) in the most deprived neighborhoods. Certain Ads—angiitis hypersensitive (5.14), ankylosing spondylitis (1.66), celiac disease (1.65), Crohn’s disease (1.21), diabetes mellitus type 1 (1.45), Graves’s disease (1.13), Hashimoto thyroiditis (1.51), psoriasis (1.15), rheumatoid arthritis (1.15), sarcoidosis (1.20), and systemic sclerosis (1.27)—remained significantly associated with high level of neighborhood deprivation after adjustment for the individual-level variables. Conclusion: This study is the largest to date analyzing the potential influence of neighborhood deprivation on ADs. Our results indicate that neighborhood deprivation may affect risk of ADs, independent of individual level sociodemographic characteristics. For health care policies, both individual and neighborhood level approaches seem to be of importance.

The association between stressful life events and respiratory infections during the first 4 years of life: The Environmental Determinants of Diabetes in the Young study

The aim of this study was to conduct a prospective analysis of the association between negative life events (NLEs) and respiratory infections in children genetically at risk for islet autoimmunity (IA) and type 1 diabetes (T1D). Long- and short-term temporal associations between NLEs and rate of respiratory infection episodes (RIEs) in 5,618 children in The Environmental Determinants of Diabetes in the Young study for at least 1 up to 4 years were analysed. All models were adjusted for demographic, day care, season of infection, and psychosocial factors associated with the rate of child RIEs between study visits. The rate of child RIEs was 26% higher in Europe (Sweden, Finland, Germany) than in the United States (rate ratio [RR] = 1.26, p < 0.001). However, the percentage of child NLEs (odds ratio [OR] = 1.18, p < 0.001) and mother NLEs (OR = 1.83, p < 0.001) was higher in the United States compared with Europe. In both continents (Europe, RR = 1.12, p < 0.001; United States, RR = 1.07, p = 0.006), high child cumulative NLEs (>1 NLE per year since study inception) was significantly associated with an increased rate of child RIEs. This large-scale prospective study confirms observations that stress may increase the susceptibility for infections in paediatric populations and suggests at least one mechanism by which stress could increase risk for IA and T1D in genetically at risk children.

The Consequences of Foster Care Versus Institutional Care in Early Childhood on Adolescent Cardiometabolic and Immune Markers: Results From a Randomized Controlled Trial

OBJECTIVE

Children exposed to institutional rearing often exhibit problems across a broad array of developmental domains. We compared the consequences of long-term, high-quality foster care versus standard institution-based care, which began in early childhood on cardiometabolic and immune markers assessed at the time of adolescence.

METHODS

The Bucharest Early Intervention Project is a longitudinal investigation of children institutionalized during early childhood (ages 6 to 30 months at baseline) who were subsequently randomized to either high-quality foster care or continued institutional care. At the age of 16 years, 127 respondents participated in a biomarker collection protocol, including 44 institutionalized children randomly assigned to receive care as usual, 41 institutionalized children randomized to be removed from institutional care and placed in high-quality foster care in infancy, and a control group of 42 demographically matched children raised in biological families. Outcomes included body mass index (BMI), systolic and diastolic blood pressure, C-reactive protein, interleukin (IL)-6, IL-8, IL-10, tumor necrosis factor α, glycosylated hemoglobin A1c, and Epstein-Barr virus antibody titers.

RESULTS

Early institutional rearing was not associated with differences in cardiometabolic or immune markers. Randomization to foster care and age of placement into foster care were also unrelated to these markers, with the exception of BMI z-score, where children assigned to care as usual had lower BMI z-scores relative to children assigned to foster care (-0.23 versus 0.08, p = .06), and older age at placement was associated with lower BMI (β = -0.07, p = .03).

CONCLUSIONS

The impact of institutional rearing on measures of cardiometabolic health and immune system functioning is either absent or not evident until later in development. These findings provide new insights into the biological embedding of adversity and how it varies developmentally and across regulatory systems and adversity type.

CLINICAL TRIAL REGISTRATION

NCT00747396.

Introduction of fish and other foods during infancy and risk of asthma in the All Babies In Southeast Sweden cohort study

The etiology of asthma includes lifestyle factors. Breastfeeding and introduction of complementary foods have been suggested to affect asthma risk, but the scientific foundation is not solid. Children from the birth cohort All Babies In Southeast Sweden study were included (n = 9727). Breastfeeding duration and timing of introduction of infant formula and food were collected prospectively during the first year. Through linkage to the Swedish Patient Register, 948 children were identified with any asthma until age 15-17 years, of which 450 cases were atopic. Breastfeeding duration was not associated to risk of asthma. Introduction of infant formula earlier than at 14 weeks of age was associated with higher risk of non-atopic asthma. Introduction of fish before 43 weeks of age, as compared to later, was associated with a lower risk of asthma, irrespective of atopic classification. Reverse causation was accounted for but did not explain the results.Conclusion: Introduction of infant formula and timing of introduction of fish seem to impact the long-term risk of doctor-diagnosed asthma. Emphasis on the growing body of evidence that early introduction of allergens offers protection against atopic disease should be considered in future recommendations. What is Known: • Breastfeeding and introduction of complementary foods might influence the risk of atopic diseases. Recently, a review stated that more studies are needed to clarify the role for asthma development. What is New: • Introduction of infant formula earlier than at 14 weeks of age was associated with a higher risk of developing non-atopic asthma. The risk was pronounced in children introduced to infant formula before 4 weeks of age while being breastfed less than 4 weeks. • Early fish introduction, before 43 weeks of age, was associated with a lower risk of asthma, independent of atopic classification of asthma.

Pet exposure in the family during pregnancy and risk for type 1 diabetes-The prospective ABIS study

BACKGROUND

The autoimmune process later leading to type 1 diabetes (T1D) seems to start very early in life. Different viruses have been suspected to contribute to the development of T1D, some already during pregnancy. As viruses may be hosted by animals and from them transferred to humans we decided to investigate if exposure to pets during pregnancy is related to later development of T1D.

METHODS

ABIS (All Babies in Southeast Sweden)-is a prospective population-based cohort study of unselected children born in southeast Sweden between Oct first 1997 to Oct first 1999. Parents of 16 384 children answered a questionnaire within 3 days after birth including information about exposure to different pets. The ABIS registry has been connected to the National Registry of diagnosis and also the national Registry of Drug prescriptions so we know that 137 children have got T1D, and they were compared with the non-diabetic population.

RESULTS

During pregnancy, 45.5% of the mothers had pet animals at home. Most common were cats (25.0%) and dogs (18.7%). Neither exposure to dogs (OR = 1.27, P = 0.23) or cats (OR = 0.81, P = 0.31) were associated to later T1D risks. However, exposure to hamsters increased the T1D risk (OR 4.21, P = 0.0007). In a multiple regression this association remained (P = 0.005) when adjusted for other possible risk factors.

CONCLUSIONS

Exposure to hamster during pregnancy seems to increase the risk of T1D in the child. One possibility could be infection by virus hosted by the pet.

Psychological stress and type 1 diabetes mellitus: what is the link?

INTRODUCTION

Type 1 diabetes mellitus (T1DM) is a chronic disease characterized by the destruction of insulin-producing β-cells of the pancreas. The current paradigm in this disease's etiopathogenesis points toward the interplay of genetic and environmental factors. Among the environmental variables, dietary factors, intestinal microbiota, toxins, and psychological stress have been implicated in disease onset. Areas covered: This review aims to investigate the relationship between psychological stress and T1DM by presenting evidence from epidemiological studies, animal models, and to provide the mechanism involved in this association. The literature search was conducted through PubMed to identify studies that investigate the connection between stress and T1DM. Experimental designs, such as case-control, and retrospective and prospective cohorts studies, were included. Expert commentary: A wide array of evidence, ranging from epidemiological to animal models, points toward the role of psychological stressors in T1DM pathogenesis. Various mechanisms have been proposed, including the hypothalamic-pituitary-adrenal (HPA) axis, influence of the nervous system on immune cells, and insulin resistance. Further research could investigate the gene-stress interactions to evaluate the risk of T1DM development.

Psychosocial Stress Over the Lifespan, Psychological Factors, and Cardiometabolic Risk in the Community

OBJECTIVE

The complex relationship between psychosocial stress over the lifetime, psychological factors, and cardiometabolic risk is still poorly understood. Accordingly, our aims were (1) to independently assess the associations between childhood adversity, life-event stress in remote (earlier than the last 5 years), and recent adulthood and cardiometabolic risk, and (2) to determine the role of psychological factors including personality, coping, and depression in these associations.

METHODS

The sample included 2674 adults, aged 35 to 66 years, randomly selected from urban area. Participants underwent a physical examination including the assessment of obesity markers, blood pressure, and blood lipid and glucose levels. Stress during adulthood was determined using the severity scores of 52 stressful life events. Information on adverse childhood experiences and major depressive disorders was collected using semistructured interviews, whereas personality traits and coping mechanisms were evaluated through questionnaires.

RESULTS

Both childhood adversity and stress in remote adulthood were associated with elevated body mass index (β [95% confidence interval {CI}] = 0.249 [0.029 to 0.468]; 0.020 [0.006 to 0.034]), waist circumference (β [95% CI] = 0.061 [0.024 to 0.099]; 0.08 [0.04 to 0.11]), and the global cardiometabolic risk score (β [95% CI] = 0.278 [0.017 to 0.540]; 0.017 [0.001 to 0.033]) after adjustment for sociodemographic, lifestyle, and psychological factors. In addition, childhood adversity was associated with low high density lipoprotein levels (β [95% CI] = -0.021 [-0.042 to 0.000]), as well as increased fat mass and systolic blood pressure levels (β [95% CI] = 0.506 [0.165 to 0.846]; 0.952 [0.165 to 1.740]) and stress in remote adulthood with apolipoprotein B levels (β [95% CI] = 0.607 [0.312 to 0.901]). Psychological factors did not account for these associations and were not effect modifiers.

CONCLUSIONS

Our data demonstrate that psychosocial stress during childhood and remote adulthood favor adiposity and abnormal lipid metabolism.

Influence of early-life parental severe life events on the risk of type 1 diabetes in children: the DiPiS study

AIMS

Stress and severe life events (SLEs) modify autoimmune disease susceptibility. Here, we aimed to establish if SLEs reported by parents during the first 2 years of life influence the risk of developing type 1 diabetes (T1D) using data from the prospective Diabetes Prediction in Skåne (DiPiS) study.

METHODS

Prospective questionnaire data recorded at 2 months (n = 23,187) and 2 years of age (n = 3784) from the DiPiS cohort of children were included in the analysis. SLEs were analyzed both by groups and as a combined variable. A Cox proportional hazards model was used to calculate hazard ratios (HRs) for T1D diagnosis for the total cohort and for the HLA-DQ2/8 high-risk population. Affected first-degree relatives, HLA-DQ risk group, paternal education level, and parents' country of birth were included as covariates.

RESULTS

There was a significantly increased risk of T1D in children with SLEs occurring during the child's first 2 years of life for both the total cohort (HR 1.67; 95% CI 1.1, 2.7; p = 0.03) and the DQ2/8 cohort (HR 2.2; 95% CI 1.1, 4.2; p = 0.018). Subgroup analysis of events related to unemployment, divorce, or family conflict showed a significant hazard for these events occurring both during and after pregnancy in the DQ2/8 cohort (HR 2.17; 95% CI 1.1, 4.3; p = 0.03 and HR 4.98; 95% CI 2.3, 11; p < 0.001, respectively) and after pregnancy in the total cohort (multiple regression HR 2.07; 95% CI 1.01, 4.2; p = 0.047).

CONCLUSIONS

Children of parents experiencing an SLE during the child's first 2 years of life were at increased risk of T1D. Further studies including those measuring immune and stress-related biomarkers are necessary to validate the findings.

Characteristics of slow progression to diabetes in multiple islet autoantibody-positive individuals from five longitudinal cohorts: the SNAIL study

AIMS/HYPOTHESIS

Multiple islet autoimmunity increases risk of diabetes, but not all individuals positive for two or more islet autoantibodies progress to disease within a decade. Major islet autoantibodies recognise insulin (IAA), GAD (GADA), islet antigen-2 (IA-2A) and zinc transporter 8 (ZnT8A). Here we describe the baseline characteristics of a unique cohort of 'slow progressors' (n = 132) who were positive for multiple islet autoantibodies (IAA, GADA, IA-2A or ZnT8A) but did not progress to diabetes within 10 years.

METHODS

Individuals were identified from five studies (BABYDIAB, Germany; Diabetes Autoimmunity Study in the Young [DAISY], USA; All Babies in Southeast Sweden [ABIS], Sweden; Bart's Oxford Family Study [BOX], UK and the Pittsburgh Family Study, USA). Multiple islet autoantibody characteristics were determined using harmonised assays where possible. HLA class II risk was compared between slow progressors and rapid progressors (n = 348 diagnosed <5 years old from BOX) using the χ² test.

RESULTS

In the first available samples with detectable multiple antibodies, the most frequent autoantibodies were GADA (92%), followed by ZnT8A (62%), IAA (59%) and IA-2A (41%). High risk HLA class II genotypes were less frequent in slow (28%) than rapid progressors (42%, p = 0.011), but only two slow progressors carried the protective HLA DQ6 allele.

CONCLUSION

No distinguishing characteristics of slow progressors at first detection of multiple antibodies have yet been identified. Continued investigation of these individuals may provide insights into slow progression that will inform future efforts to slow or prevent progression to clinical diabetes.

Early childhood infections precede development of beta-cell autoimmunity and type 1 diabetes in children with HLA-conferred disease risk

BACKGROUND

The etiology of type 1 diabetes (T1D) is largely unknown. Infections and microbial exposures are believed to play a role in the pathogenesis and in the development of islet autoimmunity in genetically susceptible individuals.

OBJECTIVE

To assess the relationships between early childhood infections, islet autoimmunity, and progression to T1D in genetically predisposed children.

METHODS

Children with human leukocyte antigen (HLA)-conferred disease susceptibility (N=790; 51.5% males) from Finland (n = 386), Estonia (n = 322), and Russian Karelia (n = 82) were observed from birth up to the age of 3 years. Children attended clinical visits at the age of 3, 6, 12, 18, 24, and 36 months. Serum samples for analyzing T1D-associated autoimmune markers were collected and health data recorded during the visits.

RESULTS

Children developing islet autoimmunity (n = 46, 5.8%) had more infections during the first year of life (3.0 vs 3.0, mean rank 439.1 vs 336.2; P = .001) and their first infection occurred earlier (3.6 vs 5.0 months; P = .005) than children with no islet autoimmunity. By May 2016, 7 children (0.9%) had developed T1D (progressors). Compared with non-diabetic children, T1D progressors were younger at first infection (2.2 vs 4.9 months; P = .004) and had more infections during the first 2 years of life (during each year 6.0 vs 3.0; P = .001 and P = .027, respectively). By 3 years of age, the T1D progressors had twice as many infections as the other children (17.5 vs 9.0; P = .006).

CONCLUSIONS

Early childhood infections may play an important role in the pathogenesis of T1D. Current findings may reflect either differences in microbial exposures or early immunological aberrations making diabetes-prone children more susceptible to infections.