Diabetes in children and adolescents from ethnic minorities: barriers to education, treatment and good metabolic control

Barriers to Type 1 Diabetes Adherence in Adolescents

Background: Adolescence is a particularly crucial period of physical, emotional, and social development and adaptation, rendering these formative years rather challenging for individuals with chronic conditions like type 1 diabetes (T1D). Despite rapid improvement in diabetes therapies, adolescents with T1D are characterized by poorer adherence to treatment regimens compared with other pediatric age groups. Insufficient adherence is strongly related to low diabetes control, increasing morbidity, and risk for premature mortality. This study aimed to provide a comprehensive overview of adolescents' most common barriers to T1D adherence, stressing the need for a deep and comprehensive understanding of these barriers. The complexity of these barriers is underscored by the diverse factors contributing to poor T1D adherence in adolescents. Methods: A narrative review was conducted, surveying four databases (PubMed, Scopus, EMBASE, and Web of Science) for full-text articles in the English language published up to June 2024. All studies related to barriers to T1D adherence in adolescents were considered. The literature was selected using selection and exclusion criteria and extracted and organized using Mendeley. Exclusion criteria included studies with insufficient data and non-peer-reviewed articles. This review revealed that adolescents face numerous obstacles to T1D adherence related to psychological factors, flux in family dynamics, perceived social pressures, therapy-related factors, transitioning responsibility, risk-taking behaviors, and pubertal changes. Conclusions: Navigating the adaptations to the different aspects of T1D, from treatment to complications and adolescents' personal growth, effectively requires a thorough understanding of the barriers of a treatment regimen that patients at this critical age face.

Looking at Diabetes Through Different Lenses: Focus Groups Conducted With Somali Canadian Families and Their Health-care Providers

OBJECTIVES

In Toronto, many families with Somali backgrounds have children living with type 1 diabetes (T1D). At our clinic, children with African and Caribbean backgrounds have higher glycated hemoglobin than children from European backgrounds. In this study, we explored the experiences and perspectives of Somali Canadian families with children living with T1D, as well as health-care professionals (HCPs) who care for them, to better understand how T1D impacts these families.

METHODS

We conducted 3 separate focus groups with Somali Canadian parents of children with T1D (n=11), Somali Canadian adolescents with T1D (n=5), and HCPs who treat patients with diabetes (n=9), respectively. A grounded theory approach to data analysis was applied to identify themes.

RESULTS

Four key themes emerged: 1) the general impact of living with diabetes, 2) the challenges of self-management, 3) uncertainty on whose job it is to manage the diabetes, and 4) how cultural differences between Canada and Somalia impact diabetes management. There was discordance in the perspectives of families and HCPs for all themes, but especially themes 1 and 3. Parents focussed on the social impact of diabetes and behavioural indicators of management success, whereas HCPs emphasized clinical measures. Families believed children should take charge of their diabetes self-management early on, whereas HCPs believed the children were not developmentally ready for this responsibility.

CONCLUSIONS

Differing perspectives of patients, families, and HCPs may lead to diverging expectations for treatment and management. Families and practitioners must work together to identify barriers to care and build strategies to promote competency and resilience in the self-management of T1D.

Perspectives of culturally and linguistically diverse families in the management of children with type 1 diabetes in Western Australia

OBJECTIVES

Children with Type 1 diabetes (T1D) from different ethnic backgrounds are growing in proportion in clinical practice and tend to have a higher risk of poor health outcomes. The study aimed to investigate the perspectives of culturally and linguistically diverse families in the management of children with T1D in Western Australia.

DESIGN

A generic qualitative approach was used. Families of children and adolescents with T1D with first-generation African, Asian or Middle Eastern background were invited to participate in a semi-structured interview. The interviews were audio-recorded, transcribed and analysed thematically. Demographic, clinical and socio-economic data were collected from all participants.

RESULTS

Fifteen families (27% African, 33% Middle Eastern, 40% Asian) participated in the study. The mean (SD) age of the child with T1D was 10.2 (5.1) years, had diabetes for 2.9 (1.6) years and an average HbA1c of 67 (15) mmol/mol. Four main themes were identified through qualitative analysis. 'Dietary challenges': lack of adequate food resources posed a barrier to determine carbohydrate amount in traditional meals; 'Linguistic challenges': inadequate reading and language skills affected comprehension of written information and the desire for pictorial resources was reported; 'Limited Support': absence of extended family made management of T1D difficult; and 'Knowledge': a key facilitator, which was acquired through clinic education, enabled families to develop skills to effectively manage T1D.

CONCLUSION

The study highlights the need to consider cultural diversity, psychosocial needs, English proficiency and health literacy when assessing and planning diabetes education. These findings will be useful to formulate a more culturally sensitive approach to diabetes education to improve care and outcomes for young people with T1D from culturally and linguistically diverse families.

Specialized Technology Education for Pumps and Pens in Underserved Populations with Diabetes

Background: Health care disparities in the use of diabetes devices are particularly prevalent, especially given the high levels of health literacy and numeracy needed to understand their use. Methods: To reduce this gap, we created lower literacy, English and Spanish multicultural guides for insulin pen and pump use. Focus groups provided input, nonbranded illustrations were designed, and simplified text was developed. The guides were implemented in our clinic for underresourced individuals in East Los Angeles, California. Subjects given the low literacy guides participated in guide-driven individual and group education, and measures were administered at baseline, 6 and 12 months. Results: Sixty-three adults with type 1 diabetes (T1D) were included, and 43 (68%) completed all 12 months of the study. Initial HbA1c was 9.2 ± 1.97 (standard deviation) with no change over the study course (12-month A1C = 9.3 ± 1.92). However, participants showed significantly reduced psychological distress due to diabetes, increased diabetes knowledge, improved self-report of health, and a trend toward reduced depression. There was also a reduction in rates of diabetic ketoacidosis (DKA). There was no change in rates of hypoglycemia, although there was an increase in fear of hypoglycemia. Conclusions: Appropriately targeted teaching guides can be used to improve various patient-reported outcomes in people with T1D, specifically, overall self-report of health, distress due to diabetes, and diabetes knowledge. Targeted teaching guides also achieved improvements in rates of DKA in T1D. While these results are encouraging, more work is needed to make a significant impact on glycemic control. Clinical Trials registration number: NCT04550585.

Above 40% of Polish children and young adults with type 1 diabetes achieve international HbA1c target - results of a nationwide cross-sectional evaluation of glycemic control: The PolPeDiab HbA1c study

BACKGROUND

Youth with type 1 diabetes (T1D) (16-18 y.o.) present worst disease control of all age groups and need structured interventions. Those should be based on unbiased, national-scale outcomes, which have not yet been successfully assessed in Poland.

OBJECTIVE

To evaluate the glycemic control in young patients with T1D in Poland.

METHOD

All pediatric diabetes care centers and the nine largest centers for adults with T1D were invited to this cross-sectional study, conducted in March 2018. Eligibility was defined as age ≤ 30 years and diabetes duration ≥1 year. Blinded samples of capillary blood and clinical questionnaires were sent to coordinating center, where HbA1c was measured by high-pressure liquid chromatography.

RESULTS

Nine adult and 25/28 pediatric centers participated, providing data for 1255 patients (50.8% males), mean age 12.3 years (95%CI:12.1-12.6) for children and 23.2 years (22.9-23.6) for adults; mean diabetes duration 7.1 years (6.8-7.3). This covered ~8% of pediatric population and 2% of 18-30-years-olds with T1D. Mean HbA1c was comparable between children and adults (57 mmol/mol [7.4%], 95%CI:56-57 mmol/mol [7.3-7.4%] vs. 57 mmol/mol [7.4%], 95%CI:56-60 mmol/mol [7.3-7.6%], p = 0.1870). Overall, 45.2% of patients achieved ISPAD target (<53 mmol/mol [<7.0%]). During the month preceding the study, 0.9% of patients experienced severe hypoglycemia and 0.4% suffered ketoacidosis. HbA1c was related to the method of insulin therapy, continuous glucose monitoring use and body weight (p < 0.0001).

CONCLUSIONS

In Polish children and young adults with T1D glycemic control expressed as HbA1c is promising in the light of ISPAD guidelines. Our results confirm the known associations between better glycemic control and the use of new technologies and maintaining optimal body weight.

The Danish "11 for Health" program raises health knowledge, well-being, and fitness in ethnic minority 10- to 12-year-olds

OBJECTIVES

This study investigated the effects of the health promotion intervention "11 for Health in Denmark" program on 10- to 12-year-old ethnic minority schoolchildren's enjoyment, health knowledge, well-being, and fitness.

METHODS

1122 Danish 5th grade schoolchildren with ethnic minority background from 154 schools were randomized (5:1) to an intervention group (IG, n = 944) or a control group (CG, n = 178). The IG and CG were also divided into subgroups of children active in a sports club (IGPA: n = 644; CGPA: n = 122) and not active in a sports club (IGPI: n = 300, CGPI: n = 56). IG participated in the "11 for Health in Denmark" 11-week program, consisting of 2 × 45 min per week of football drills, small-sided games, and health education, whereas CG continued their regular activities. Pre-post physical testing and questionnaires were applied (short version of the multidimensional well-being questionnaire KIDSCREEN-27, and a 34-item health knowledge questionnaire).

RESULTS

The "11 for Health in Denmark" program was rated moderate-to-high on a 1-5 scale for enjoyment by girls (3.57) and boys (3.65). The intervention had positive between-group effect on health knowledge in relation to hygiene (IG vs GC: 10.6% points (CI95%: 6.9:14.3), p < 0.05), nutrition (9.6% point (CI95%: 7.4:11.8), p < 0.01) and physical activity 4.4% points (CI95%: 2.2:6.6) as well as overall health knowledge (5.7% points, (CI95%: 4.3;7.1), p < 0.05), with similar effects for girls and boys. The IGPI subgroup showed a positive effect on well-being (p = 0.04, school and learning) and also fitness effects on performance and VO₂  max (p = 0.02: p = 0.01). The IGPA subgroup showed a positive effect on fitness scores (p = 0.02, BMI).

CONCLUSION

The intervention program was enjoyable and had a positive impact on health knowledge of ethnic minority background schoolchildren. In addition, the intervention program had the strongest positive effects on well-being and fitness scores for the non-sports club-active children.

Type 1 diabetes outcomes of children born in Israel of Eritrean asylum seekers

AIMS

Disparities in health outcomes in pediatric type 1 diabetes (T1D) based on race/ethnicity and socioeconomic position (SEP) have been reported. We compared T1D characteristics between Eritrean status-less children living in Israel and native-born Israeli children.

METHODS

This observational study compared 7 Eritrean and 28 Israeli children (< 8 years old at T1D diagnosis) who were diagnosed in a single diabetes center during 2015-2019. Sociodemographic and diabetes-related data from diagnosis until the last clinic visit were retrieved from their medical files.

RESULTS

At diagnosis, the mean age was 4.8 ± 2.2 years, 17 (48.6%) had diabetic ketoacidosis with a mean HbA1c level of 10.5 ± 2.1% (91.3 mmol/mol) and 29 (82.9%) had ≥ 2 pancreatic autoantibodies. The mean T1D duration of follow-up was 2.7 ± 1.4 years. Overall glycemic control during follow-up (> 6 months from diagnosis, mean number of samples 10.6 ± 5.2) was good, with mean, best, and peak HbA1c levels of 7.4 ± 0.8% (57.4 mmol/mol), 6.7 ± 0.7% (49.7 mmol/mol), and 8.1 ± 1.1% (65 mmol/mol), respectively. Thirty-two children (91.4%) used continuous glucose monitoring devices (CGMs), and the mean time from diagnosis to CGM initiation was 10.8 ± 14.1 months. CGM metrics: time CGM active: 95.4 ± 3.8%, mean glucose level: 170.0 ± 27.0 mg/dl (9.4 mmol/L), time-in-range: 56.4 ± 14.7%, time-below-range: 5.5 ± 5.7%, and time-above-range: 38.6 ± 16.1%. Diabetes-related parameters at diagnosis and during follow-up were similar between groups. Eritrean children had significantly lower SEPs (P < 0.001) and parental education levels (P < 0.001). Correlations between SEP and diabetes parameters and SEP and growth parameters were not significant.

CONCLUSIONS

Eritrean status-less children in Israel achieved glycemic targets similar to those of Israeli children, perhaps reflecting uniformity in the standard of care and CGM usage.

Effectiveness of a tailored medical support to overcome the barriers to education, treatment and good metabolic control in children with type-1 diabetes from ethnic minorities

Aim:

To analyze the effectiveness of a tailored medical support to help children from ethnic minorities to achieve the same good metabolic control of autochthonous peers with type-1 diabetes (T1D).

Methods:

Children <10 years of age belonging to ethnic minority (EM) families (Group 1) were compared with autochthonous peers (Group 2) who received the diagnosis of T1D in 2014-2016. The Protocol for minorities included other than the standard protocol: booklets translated in ethnic minority languages; weekly visits at home or at school; family-guides; clinic visits supported by professional interpreters. After twelve months of this approach, parents of ethnic minority children answered a short questionnaire concerning satisfaction about educational tools for diabetes management.

Results:

From 1^st January 2014 to December 31^st 2016, 72 children received the diagnosis of T1D at the University Children Hospital of Parma, Italy. Nineteen children belonged to an EM family (26.38%), and were included in the Group 1. Twenty-one autochthonous peers were randomly recruited for the Group 2. T1D was diagnosed at the same mean age in Group 1 (5.2±2.2) and in Group 2 patients (5.7±2.4). Metabolic derangements at diagnosis were more severe in Group 1 than in Group 2 patients. However, patients of both Groups showed a similar decrease in HbA1c levels during the first 3 and 6 months post diagnosis. Patients did not differ in mean insulin doses at discharge and at follow up. The calls to the emergency toll-free telephone number were more numerous from the parents from Group 1 than from the parents of Group 2. Total cost to implement the tailored protocol in Group 1 was higher of 87% compared with the standard protocol used for Group 2 patients. Great majority of parents reported to be satisfied with the provided diabetes education program.

Conclusions:

1The results of this study suggested that children from EM families can achieve the same good metabolic control of autochthonous peers with T1D, providing a cost-effective tailored support to their family members. (www.actabiomedica.it)

National Swedish study of immigrant children with type 1 diabetes showed impaired metabolic control after three years of treatment

AIM

This study examined the clinical status and socio-demographic conditions of children with type 1 diabetes at baseline and after three years of treatment, comparing those born to immigrant parents and Swedish parents.

METHODS

This observational nationwide population-based cohort study used prospectively collected registry data from Swediabkids, the National Quality Registry for Paediatric Diabetes in Sweden from 2000 to 2010. Of the 13 415 children with type 1 diabetes, there were 879 born to immigrant parents. We selected three children born to Swedish parents from the same registry for each immigrant child matching them by gender, age and year of diabetes onset (n = 2627; with 10 control children missing probably due to the matching procedure).

RESULTS

Immigrant children had a higher median glycated haemoglobin level (HbA1c) than their Swedish peers, but there was no difference in the frequency of hypoglycaemia or ketoacidosis between the two cohorts. A linear regression model with HbA1c as a dependent variable showed that insulin units per kilogram of body weight were the main reason for inferior metabolic control.

CONCLUSION

Children with type 1 diabetes born to immigrant parents had inferior metabolic control three years after disease onset compared to children with Swedish born parents. Social family support and educational coping programmes are needed to improve treatment outcomes in immigrants with diabetes.

Lower Prevalence of Atopic Dermatitis and Allergic Sensitization among Children and Adolescents with a Two-Sided Migrant Background

In industrialized countries atopic diseases have been reported to be less likely in children and adolescents with a migrant background compared to non-migrants. This paper aimed at both examining and comparing prevalence of asthma, allergic rhinoconjunctivitis and atopic dermatitis and allergic sensitization to specific IgE antibodies in children and adolescents with and without a migrant background. Using data of the population-based German Health Interview and Examination Survey for children and adolescents (KiGGS; n = 17,450; 0–17 years), lifetime and 12-month prevalence of atopic diseases and point prevalence of 20 common allergic sensitizations were investigated among migrants compared to non-migrants. Multiple regression models were used to estimate the association of atopic disease and allergic sensitization with migrant background. In multivariate analyses with substantial adjustment we found atopic dermatitis about one-third less often (OR 0.73, 0.57–0.93) in participants with a two-sided migrant background. Statistically significant associations between allergic sensitizations and a two-sided migrant background remained for birch (OR 0.73, 0.58–0.90), soybean (OR 0.72, 0.54–0.96), peanut (OR 0.69, 0.53–0.90), rice (OR 0.64, 0.48–0.87), potato (OR 0.64, 0.48–0.85), and horse dander (OR 0.58, 0.40–0.85). Environmental factors and living conditions might be responsible for the observed differences.

Assessing the Acceptability and Usability of an Internet-Based Intelligent Health Assistant Developed for Use among Turkish Migrants: Results of a Study Conducted in Bremen, Germany

The Internet offers a new chance for health professionals to reach population groups not usually reached through traditional information channels, for example, migrants. Criticism has, however, been raised that most health information on the Internet is not easy to read and lacks cultural sensitivity. We developed an Internet-based bilingual health assistant especially for Turkish migrants in Germany, tested its acceptance, and evaluated its usability in a participatory research design with families with and without Turkish migrant background. The interactive health assistant covered the following: nutrition, physical activity, overweight, diabetes, as well as pregnancy and pregnancy support. The idea of an Internet-based health assistant was generally accepted by all participants of the evaluation study, as long as it would be incorporated in existing appliances, such as smartphones. The bilingual nature of the assistant was welcomed especially by first generation migrants, but migrant participants also indicated that not all health information needed to be made available in a culture-specific way. The participants were least satisfied with the nutrition component, which they felt should include recipes and ingredients from the culture of origin, as well as specific aspects of food preparation.

The relation between awareness of personal resources and metabolic control in children and adolescents with type 1 diabetes

INTRODUCTION

The study aims to elucidate whether awareness of personal resources, such as positive attributions and beliefs or social support, affects metabolic control in children and adolescents with type 1 diabetes. In addition, it will be determined to what extent metabolic control is influenced by concordance between children and parents regarding awareness of resources and the parents' ability to adopt their children's perspective. Also, the children's wishes particularly in relation to their illness will be investigated, as well as the kind of advice they would offer to fellow patients.

METHODS

Seventy-eight children/adolescents with type 1 diabetes completed the Essen Resource Inventory for Children and Adolescents including personal, social, structural, and migration-specific resources. In addition, children/adolescents and their parents completed a systemic-oriented, diabetes-specific resource questionnaire in order to explore the parents' ability to adopt their children's perspective.

RESULTS

Resources such as body awareness and open-minded attitude to the disease were associated with metabolic control. Particularly, resources associated to a migration background were found to be inversely correlated with hemoglobin A1c (HbA1c) value. Moreover, it was shown that the parents' ability to adopt their children's perspective was associated with improved metabolic control. Children advising fellow patients to accept the disease showed the best HbA1c value.

DISCUSSION

This data identified specific modifiable factors related to metabolic control that can be addressed during counseling of pediatric patients. Also the parents' ability for adopting their child's perspective was identified as a relevant factor which should be considered during clinical counseling of young type 1 diabetes patients.

Understanding Cultural Beliefs in Families of Somali Children with Diabetes in the Twin Cities, Minnesota

Describe cultural beliefs related to diabetes in Minnesota Somali children with type 1 diabetes (T1D), and compare their diabetes control to that of non-Somali children with diabetes. A cross-sectional study involving Somali children ≤ 19 years with T1D at the University of Minnesota Masonic Children's Hospital and Children's Hospitals and Clinics of Minnesota. A survey was administered to parents of all participants and to children aged ≥ 12 years. Data were collected by history and from the medical record. Twenty-five Somali children participated, with 24 parent-child pairs (2 siblings). Mean participant age was 12.2 ± 5.2 (36% female). Seventy-one percent of parents indicated the child was "the same as before" other than having to do diabetes cares. Families were coping well, and the child was not treated differently than siblings. Performance of routine cares was described as the hardest part about having diabetes, but this was not related to traditional culture or religion. One notable exception was difficulty performing carbohydrate counting on Somali foods. Respondents were appreciative of the education provided by the diabetes team. Less than 10% used herbal supplements in addition to insulin. Mean HbA1c in Somali children was higher than the overall pediatric clinic average, 9.5 ± 1.6 % versus 8.8 ± 1.6 (p = 0.01). The difference was largely due to adolescent patients. The majority of Somali families cope well with diabetes and have a positive attitude towards the diabetes education. Glycemic control in adolescents is worse than in non-Somali peers. There is a need for culture-specific dietary instruction materials.

Conceptions of diabetes and diabetes care in young people with minority backgrounds

Adolescents with type 1 diabetes (T1DM) need stable self-care routines for good metabolic control to minimize future cardiovascular health complications. These routines are demanding, and might be particularly challenging in underprivileged groups. The aim of this study was to gain in-depth knowledge on the experience of adolescents with T1DM and a non-Swedish background regarding factors that might influence their ability to take care of themselves; in particular, factors that might influence diabetes management routines, their social situation, and the support they receive from caregivers. We interviewed 12 adolescents with T1DM and minority backgrounds. The results indicated resources and constraints in the adolescents' social context and in the health care organization. The adolescents developed conceptions that helped to explain and excuse their self-care failures, and their successes. These findings highlight the importance of integrating T1DM as part of the individual's personal prerequisites. We discuss implications for the organization of diabetes care for adolescents.

Equal access to health care may diminish the differences in outcome between native and immigrant patients with type 1 diabetes

BACKGROUND/OBJECTIVE

Previous studies have found that ethnicity influences glycemic control. We hypothesized that differences between Nordic and non-Nordic patients are less pronounced for children with type 1 diabetes in high incidence countries in Northern Europe.

RESEARCH DESIGN AND METHODS

We investigated patients aged 0-15 yr in national pediatric registers in Denmark (D), Iceland (I), Norway (N), and Sweden (S) (2006-2009). Ethnic origin was defined by maternal country of birth as being Nordic or non-Nordic (other countries).

RESULTS

The cohort (n = 11,908, 53.0% boys, onset age 7.7 (3.9) yr, diabetes duration 6.1 (3.6) yr, [mean, (SD)]) comprised 921 (7.7%) non-Nordic patients. The frequencies of non-Nordic patients according to country of residence were: 5.7% (D), 2.7% (I), 5.5% (N), and 9.4% (S). Sex distribution and BMI z-score did not differ between Nordic and non-Nordic patients, but non-Nordic patients were 0.5 yr younger at onset than Nordic patients (p < 0.0006). Non-Nordic patients had a lower number of daily insulin bolus injections and higher daily insulin doses compared to their Nordic peers. Patients of non-Nordic origin had slightly higher HbA1c levels (0.6-2.9 mmol/mol, p < 0.001) and, with the exception of Norway, were less frequently treated with CSII (p = 0.002) after adjusting for confounders.

CONCLUSIONS

The reported differences in glycemic regulation between Nordic and non-Nordic type 1 diabetes children and adolescents in four Nordic countries are diminutive, but persist after accounting for treatment intensity.

Demographic and personal factors associated with metabolic control and self-care in youth with type 1 diabetes: a systematic review

Optimal use of recent technological advances in insulin delivery and glucose monitoring remain limited by the impact of behaviour on self-care. In recent years, there has been a resurgence of interest in psychosocial methods of optimizing care in youth with type 1 diabetes. We therefore sought to examine the literature for demographic, interpersonal and intrapersonal correlates of self-care and/or metabolic control. Studies for this systematic review were obtained via an electronic search of Medline, Embase, Cumulative Index to Nursing and Allied Health Literature and PsycINFO databases. Seventy studies fulfilled the inclusion criteria. These studies have indicated that identifiable individual characteristics in each domain are robustly associated with metabolic control and/or self-care in children and adolescents. We present these characteristics and propose a theoretical model of their interactions and effect on diabetes outcomes. There is currently no consensus regarding patient selection for insulin pump therapy. In this era of scarce healthcare resources, it may be prudent to identify youth requiring increased psychosocial support prior to regimen intensification. The importance of this review lies in its potential to create a framework for rationally utilizing resources by stratifying costly therapeutic options to those who, in the first instance, will be most likely to benefit from them.

Prevalence of diabetic retinopathy in various ethnic groups: a worldwide perspective

The alarming rise in diabetes prevalence is a global public health and economic problem. Diabetic retinopathy is the most common complication of diabetes and the leading cause of blindness among working-age populations in the Western world. Screening and prompt treatment of diabetic retinopathy are not top priorities in many regions of the world, because the impacts of other causes of preventable blindness remain an issue. Ethnicity is a complex, independent risk factor for diabetic retinopathy. Observations from white populations cannot be extrapolated fully to other ethnic groups. The prevalence of diabetic retinopathy, sight-threatening diabetic retinopathy, and clinically significant macular edema are higher in people of South Asian, African, Latin American, and indigenous tribal descent compared to the white population. Although all ethnic groups are susceptible to the established risk factors of diabetic retinopathy-such as length of exposure and severity of hyperglycemia, hypertension, and hyperlipidemia-ethnic-specific risk factors also may influence these rates. Such risk factors may include differential susceptibility to conventional risk factors, insulin resistance, differences in anthropometric measurements, truncal obesity, urbanization, variations in access to healthcare systems, genetic susceptibility, and epigenetics. The rates of nonproliferative diabetic retinopathy appear to be declining in the United States, supporting the observation that better medical management of diabetes and prompt treatment of sight-threatening diabetic retinopathy substantially improve the long-term diabetic retinopathy incidence; studies from other parts of the world are limited and do not mirror this finding, however. We examine the ethnicity and region-based prevalence of diabetic retinopathy around the world and highlight the need to reinforce ethnicity-based screening and treatment thresholds in diabetic retinopathy.

Lack of individualized perspective: a qualitative study of diabetes care for immigrants in Sweden

This study describes the care provided by a diabetes nurse specialist, and the care needs expressed by people with type 2 diabetes mellitus and an immigrant background. Clinical encounters between a diabetes nurse specialist and 10 people diagnosed with type 2 diabetes mellitus were observed and analyzed by means of qualitative content analysis. One theme, "the diabetes nurse specialist as the conductor of the visit", and four categories emerged from the findings, illustrating the power imbalance between the patients and the diabetes nurse specialist, as well as the lack of an individual perspective. Shifting from a medical perspective to one of openness towards the people's experiences provides a possibility for caregivers to empower patients suffering from type 2 diabetes mellitus. The medical perspective seemed to steer the visit towards curative activities. Thus, technique-centered care should be developed by including individualized care.

Prevalence and characteristics of diabetes among Somali children and adolescents living in Helsinki, Finland

OBJECTIVE

We compared the prevalence and characteristics of diabetes between Somali and Finnish children in the City of Helsinki.

SUBJECTS AND METHODS

Ten Somali and 310 non-Somali children <16 yr of age were treated for diabetes in Helsinki at the end of 2007. We analyzed autoantibodies, HLA alleles, and serum 25-hydroxy-vitamin D [S25(OH)D] concentrations.

RESULTS

The prevalence of diabetes was 40/10,000 (95% CI 19-73/10,000) for the Somali children and 37/10,000 (95% CI 33-41/10,000) for the background population. At least one autoantibody was detected in all seven Somali patients sampled within 18 months after the diagnosis. Most Somalis (75%) carried HLA-conferred susceptibility to type 1 diabetes (T1D), DR3-DQ2 being the dominating HLA haplotype. Low S25(OH)D levels (<40 nmol/L) were seen in 83% of the Somali patients and in 60% of their siblings.

CONCLUSIONS

These data show that (i) Somali children have autoimmune diabetes, (ii) the prevalence of T1D is similar among Somali and Finnish children, and (iii) both affected and unaffected Somali children have low concentrations of S25(OH)D.

Early markers of glycaemic control in children with type 1 diabetes mellitus

Background

Type 1 diabetes mellitus (T1DM) may lead to severe long-term health consequences. In a longitudinal study, we aimed to identify factors present at diagnosis and 6 months later that were associated with glycosylated haemoglobin (HbA_1c) levels at 24 months after T1DM diagnosis, so that diabetic children at risk of poor glycaemic control may be identified.

Methods

229 children <15 years of age diagnosed with T1DM in the Auckland region were studied. Data collected at diagnosis were: age, sex, weight, height, ethnicity, family living arrangement, socio-economic status (SES), T1DM antibody titre, venous pH and bicarbonate. At 6 and 24 months after diagnosis we collected data on weight, height, HbA_1c level, and insulin dose.

Results

Factors at diagnosis that were associated with higher HbA_1c levels at 6 months: female sex (p<0.05), lower SES (p<0.01), non-European ethnicity (p<0.01) and younger age (p<0.05). At 24 months, higher HbA_1c was associated with lower SES (p<0.001), Pacific Island ethnicity (p<0.001), not living with both biological parents (p<0.05), and greater BMI SDS (p<0.05). A regression equation to predict HbA_1c at 24 months was consequently developed.

Conclusions

Deterioration in glycaemic control shortly after diagnosis in diabetic children is particularly marked in Pacific Island children and in those not living with both biological parents. Clinicians need to be aware of factors associated with poor glycaemic control beyond the remission phase, so that more effective measures can be implemented shortly after diagnosis to prevent deterioration in diabetes control.

The geoepidemiology of type 1 diabetes

Type 1 diabetes (T1D) is a chronic autoimmune disease characterized by absolute insulin deficiency resulting from the progressive immune-mediated destruction of pancreatic islet beta cells. It is thought to be triggered by as yet unidentified environmental factors in genetically susceptible individuals, the major genetic contribution coming from loci within the HLA complex, in particular HLA class II. The worldwide incidence of T1D varies by at least 100-fold, being highest in Finland and Sardinia (Italy) and lowest in Venezuela and China. The incidence has been increasing worldwide at an annual rate of approximately 3%. While genetic factors are thought to explain some of the geographic variability in T1D occurrence, they cannot account for its rapidly increasing frequency. Instead, the declining proportion of newly diagnosed children with high-risk genotypes suggests that environmental pressures are now able to trigger T1D in genotypes that previously would not have developed the disease during childhood. Although comparisons between countries and regions with low and high-incidence rates have suggested that higher socioeconomic status and degree of urbanization are among the environmental factors that play a role in the rising incidence of T1D, the findings are too inconsistent to allow firm conclusions. Morbidity and mortality as well as causes of death also show considerable geographic variation. While glycemic control has been identified as a major predictor of the micro- and macrovascular complications of T1D and shows considerable geographical variability, it does not appear to be the only factor involved in the regional differences in complication rates. The role of genetics in susceptibility to nephropathy, retinopathy and other diabetic complications largely remains to be explored.

Ethnicity and social deprivation independently influence metabolic control in children with type 1 diabetes

AIMS/HYPOTHESIS

This study was performed to evaluate the influence of ethnicity and socioeconomic status (SES) on metabolic control in a population-based cohort of children with type 1 diabetes mellitus, and to evaluate whether any relationship between ethnicity and HbA(1c) is mediated by SES.

METHODS

We performed a retrospective review of all patients under age 16 years with type 1 diabetes (n = 555) from 1995 to 2005 in the greater Auckland region, New Zealand. Diabetes care variables and HbA(1c) values were collected prospectively, during clinic visits.

RESULTS

The mean population HbA(1c) was 8.3 +/- 1.3%. Maori and Pacific patients had poorer metabolic control than their European counterparts (9.1% and 9.3% vs 8.1%, p < 0.001) and higher rates of moderate to severe hypoglycaemia (31.1 and 24.8 vs 14.9 events/100 patient-years, p = 0.03). In multiple linear regression analysis, both ethnicity and SES were independently associated with HbA(1c) (p < 0.001). Other factors associated with higher HbA(1c) level were longer duration of diabetes, higher insulin dose, lower BMI z score and less frequent blood glucose monitoring (p < 0.001).

CONCLUSIONS/INTERPRETATION

Both ethnicity and SES independently influenced metabolic control in a large, unselected population of children with type 1 diabetes. Irrespective of SES, Maori and Pacific youth with type 1 diabetes were at greater risk of both moderate to severe hypoglycaemia and long-term complications associated with poor metabolic control.