Longitudinal screening of serum lipids in children and adolescents with Type 1 diabetes in a UK clinic population

Dyslipidemia and ANGPTL8 evaluation in young females with Type 1 diabetes mellitus

PURPOSE

ANGPTL8, commonly referred to as betatrophin, has demonstrated promise as a dependable marker for the onset of complications associated with diabetes mellitus, such as dyslipidemia. The objective of this study is to evaluate the lipid profile and ANGPTL8 levels in people diagnosed with Type 1 Diabetes Mellitus (T1DM).

METHODS

A retrospective case-control study was performed on a group of 100 adolescent females, aged 13-17 years. This group consisted of individuals diagnosed with T1DM from the Diabetes and Endocrine Department at Medina's King Fahad Hospital in Saudi Arabia. Additionally, 100 healthy adolescent females of the same age range were included as controls. The hospital conducted laboratory studies to evaluate glucose, HbA1c, insulin, and lipid profiles. The ANGPTL8 levels were quantified using Enzyme-Linked Immunosorbent Assay (ELISA).

RESULTS

Patients with T1DM had ANGPTL8 levels that were twice as high as those observed in individuals without any health conditions. The two groups had contrasting levels of fasting blood glucose (FBG), glycated hemoglobin (HbA1c), C-peptides, triacylglycerol (TG), and cholesterol, along with elevated Atherogenic Index of Plasma readings. Diabetes mellitus patients had considerably elevated values compared to the control group. There was a significant correlation between ANGPTL8 concentrations and lipid abnormalities, with P-values less than 0.05. 56% of the 100 patients exhibited dyslipidemia. The research found a correlation between dyslipidemia and elevated levels of ANGPTL8 in diabetic patients. The concentration of ANGPTL8 had a positive correlation with glucose, HbA1c, TG, and C-peptides while displaying a negative correlation with high-density lipoprotein cholesterol (HDL-C).

CONCLUSION

ANGPTL8 levels were found to be elevated in Saudi young women who were diagnosed with TIDM. ANGPTL8 may potentially contribute to dyslipidemia in individuals with T1DM, hence increasing the susceptibility to cardiovascular disease (CVD). Therefore, ANGPTL8 has the potential to impact lipid metabolism, namely Triglycerides, as a biological route. The results highlight the need to analyze lipid profiles and do ANGPTL8 testing in young females diagnosed with T1DM at an early stage to prevent complications.

Low-density lipoprotein cholesterol in adolescents and young adults with type 1 diabetes: Data from the Australasian Diabetes Data Network registry

AIM

To determine low-density lipoprotein cholesterol (LDL-C) screening frequency and levels, and factors associated with elevated LDL-C, in Australasian youth with type 1 diabetes (T1D).

METHODS

Data were extracted from the Australasian Diabetes Data Network (ADDN), a prospective clinical quality registry, on all T1D healthcare visits attended by young people aged 16-25 years (with T1D duration of >1 year) between January 2011 and December 2020. The primary outcomes were elevated LDL-C > 2.6 mmol/L (100 mg/dL) and threshold for treatment: >3.4 mmol/L (130 mg/dL), according to consensus guidelines. Multivariable Generalised Estimated Equations (GEE) were used to examine factors associated with elevated LDL-C across all visits.

RESULTS

A cohort of 6338 young people (52.6% men) were identified, of whom 1603 (25.3%) had ≥1 LDL-C measurement documented. At last measurement, mean age, age at T1D diagnosis and T1D duration were 18.3 ± 2.4, 8.8 ± 4.5 and 8.9 ± 4.8 years, respectively. LDL-C was elevated in 737 (46.0%) and at the treatment threshold in 250 (15.6%). In multivariable GEE elevated LDL-C continuously was associated with older age (OR = 0.07; 0.01-0.13, p = 0.02), female sex (OR = 0.31; 0.18-0.43; p < 0.001), higher HbA1c (OR = 0.04; 0.01-0.08; p = 0.01) and having an elevated BMI (OR = 0.17, 0.06-0.39, p < 0.001).

CONCLUSIONS

LDL-C screening and levels are suboptimal in this cohort, increasing future cardiovascular complication risk. There is an urgent need to understand how healthcare services can support improved screening and management of dyslipidaemia in this population.

Factors Associated With the Development of Dyslipidemia Among Pediatric Patients With Diabetes: A Single-centre-based Study

OBJECTIVES

The prevalence of pediatric diabetes is increasing. Dyslipidemia is an important modifiable cardiovascular disease risk factor often present in children with diabetes. In this study, we evaluated the adherence to Diabetes Canada 2018 lipid screening guidelines in a pediatric diabetes program to determine the prevalence of dyslipidemia in youth with diabetes and to identify risk factors related to dyslipidemia.

METHODS

This retrospective chart review included patients at McMaster Children's Hospital with diabetes (types 1 and 2), who were at least 12 years of age as of January 1, 2019. Extracted data included age, sex, family history of diabetes or dyslipidemia, date of diagnosis, body mass index, glycemia monitoring system used, lipid profile, glycated hemoglobin (A1C), and thyroid-stimulating hormone values at the time the lipid profile was measured. Statistical methods included descriptive statistics and logistic regression modelling.

RESULTS

Of the 305 patients included, 61% had a lipid profile measured according to guidelines, 29% had lipid screening completed outside of the recommended window, and 10% had no lipid profile on record. Among screened patients, 45% had dyslipidemia, most commonly hypertriglyceridemia (35%). Dyslipidemia was highest amongst those with type 2 diabetes, obesity, older age, short duration of diabetes, higher A1C, and those who used capillary blood glucose for monitoring (p<0.05).

CONCLUSIONS

A high proportion of patients were screened for dyslipidemia, but many outside the recommended window. Dyslipidemia is highly prevalent in this patient population and was associated with the presence of obesity, but 44% of patients without obesity also had dyslipidemia.

Evaluation of the dietary inflammatory index in children and adolescents with type 1 diabetes mellitus and its relationship with nutritional status and metabolic control

OBJECTIVES

The aim of this study was to evaluate the association of the dietary inflammatory index (DII) with the nutritional status and metabolic control of children and adolescents with type 1 diabetes mellitus.

METHODS

This was a cross-sectional study that examined data of children and adolescents ages 7 to 16 y diagnosed with type 1 diabetes mellitus. Dietary intake was assessed using a 24-h dietary recall, from which the DII was calculated. The outcomes were body mass index, lipid profiles (low-density lipoprotein cholesterol and non-high-density lipoprotein cholesterol), and glycated hemoglobin. The DII was evaluated in tertiles and in a continuous way. Multiple linear regression was adopted in the analysis, with P < 0.05 considered significant.

RESULTS

Overall, 120 children and adolescents with a mean age of 11.7 (± 2.8) y were included, 53.3% (n = 64) of whom were girls. Excess weight was present in 31.7% participants (n = 38). The average DII was +0.25, ranging from -1.11 to +2.67. Higher values of selenium (P = 0.011), zinc (P = 0.001), fiber (P < 0.001), and other micronutrients were observed in the first tertile of the DII (diet with more antiinflammatory potential). The DII appeared as a predictor of body mass index (P = 0.002; β = 0.23; 95% confidence interval [CI], 0.39-1.75) and non-high-density lipoprotein cholesterol (P = 0.034; β = 0.19; 95% CI, -13.5 to 0.55). There was a tendency for DII to be associated with glycemic control (P = 0.09; β = 0.19; 95% CI, -0.04 to 0.51).

CONCLUSIONS

The inflammatory potential of the diet was associated with increased body mass index and aspects related to metabolic control in children and adolescents with type 1 diabetes mellitus.

Prevalence of LDL-hypercholesterolemia and other cardiovascular risk factors in young people with type 1 diabetes

BACKGROUND

Mortality and morbidity in people with Type 1 diabetes (T1D) is mainly caused by cardiovascular disease (CVD). Early treatment of cardiovascular risk factors (CVRFs) is of great importance.

OBJECTIVE

To analyze the prevalence of LDL-hypercholesterolemia and other CVRFs in youth with T1D.

METHODS

Clinical and laboratory parameters, and vascular thickness measurement were obtained in youth with T1D (age 6-18 years, T1D duration >1 year) attending a diabetes clinic. LDL-hypercholesterolemia, microalbuminuria and arterial hypertension were defined as CVRFs.

RESULTS

A total of 333 youth (48% girls; age: 13.3 years [10.3-15.5], median [interquartile range]) participated in the study. The T1D duration was 5.9 years [3.5-9.4] with HbA1c of 7.4% [6.8-8.0]. Intima media thickness (N=223) was 538.0 µm [470.0-618.0]). LDL-hypercholesterolemia was present in 30 participants (9%; 18 girls; age: 14.3 years [11.2-15.7]). None of the participants had persistent microalbuminuria, although 59 (18.3%) had elevated albumin excretion in a random urine specimen. LDL-hypercholesterolemia was associated with increased blood pressure (p<0.05), insulin requirement (p<0.05), HbA1c (p<0.05), triglyceride (p<0.001) and total cholesterol (p<0.001), and a family history of premature CVD (p<0.001), but negatively correlated with HDL cholesterol levels (p<0.05). Sex, pubertal status, duration of diabetes, type of therapy, and physical activity did not differ between participants with and without LDL- hypercholesterolemia. Arterial hypertension was present in 11 participants (3.3%; 4 girls; age: 14.1 years [11.1-16.1]).

CONCLUSION

LDL-hypercholesterolemia affected 9% of youth with T1D in this cohort and was associated with other CVRFs. A holistic therapeutic concept for these young people is essential.

Longitudinal trends in lipid profile in indian children and youth with type-1 diabetes: a 5-year follow up from a single centre

INTRODUCTION

High prevalence of dyslipidaemia in children and adolescents with type-1 diabetes (T1D) places them at increased risk of developing atherosclerosis leading to mortality caused by cardiovascular disease(CVD). Thus, screening for fasting blood lipids when diabetes is stabilized in children aged 11 years and above is routinely recommended with follow-up every 5 years.

OBJECTIVES

(1) To characterize the lipid profile of children and adolescents with respect to diabetes duration. (2) To describe longitudinal changes in lipid profile over a 5-year period in patients with T1D.

METHODS

This longitudinal 5-year follow-up study included 112 patients with T1D aged 3-18 years. Demographic data, anthropometry and laboratory measurements were performed using standard protocols at baseline and endline. P value < 0.05 was considered significant.

RESULTS

The prevalence of dyslipidaemia in our study was 49.5% with abnormal LDL as the most frequently deranged parameter. Duration of illness played a major role in deterioration of lipid profile mediated by triglyceride and VLDL. Duration of illness and fibre intake in diet significantly predicted the change in lipid profile which were driven by triglycerides and VLDL. Glycemic control, insulin sensitivity and serum TSH also significantly altered components of lipid profile with no impact on overall dyslipidaemia. A total of 6.5% subjects had LDL concentrations >130 mg/dl and the same proportion had non-HDL cholesterol concentrations >145 mg/dl at baseline while at endline, 11.9% subjects had LDL concentrations >130 mg/dl and 15.6% subjects had non-HDL cholesterol concentrations >145 mg/dl. 28.6% subjects with LDL > 130 mg/dl and non-HDL cholesterol >145 mg/dl at baseline had persistently elevated concentrations while 10.3% and 14.4% additional subjects developed elevated LDL and non-HDL cholesterol concentrations respectively during the study period.

CONCLUSIONS

The deterioration of lipid profile in T1D, due to increase in disease duration was chiefly mediated by increase in serum triglyceride and VLDL concentrations which may be prevented by improving glycaemic control, insulin sensitivity and fibre intake in diet.

Children and adolescents with diabetes at Tygerberg Hospital – at risk of cardiovascular complications?

Background. In South Africa, the prevalence of dyslipidaemia and hypertension (HT) in paediatric diabetes patients is unknown. Objectives. To determine the prevalence of dyslipidaemia and HT in paediatric diabetic patients seen at Tygerberg Hospital (TBH) and establish whether either is associated with body mass index (BMI), glycosylated haemoglobin (HbA1c) or duration of diabetes. Further, to determine whether the prevalence differs between two specified periods.Methods. A retrospective study of 154 diabetic patients, aged 1 - 19 years, seen at TBH between 2007 and 2017, was undertaken. The following data were recorded: age; sex; duration of disease (time since diagnosis); height; weight; blood pressure; HbA1c; high-density lipoprotein cholesterol (HDL-C); triglycerides (TG); and low-density lipoprotein cholesterol (LDL-C).Results. More than half of the patients (57.8%; n=89/154; 95% confidence interval (CI) 51.7 - 65.0) had dyslipidaemia, 16.3% (n=24/147) had low HDL-C levels, 53.8% (n=78/145) had high LDL-C levels and 14.9% (n=22/148) had raised TG levels. Nearly half of the patients (48.7%; n=75/154; 95% CI 41.6 - 55.1) were hypertensive and 93.5% (n=144/154) were poorly controlled (HbA1c >7.5%). Dyslipidaemia was not associated with HT or BMI percentile and its prevalence did not change between the two specified periods. Prevalence of dyslipidaemia and HT was not associated with duration of diabetes. About one-third (30.8% (n=4/13); 95% CI 11.9 - 59.3) of the pre-adolescents and 60.3% (n=85/141; 95% CI 51.9 - 68.1) of the adolescents had dyslipidaemia (p=0.04). Dyslipidaemia was diagnosed in 62.6% (n=82/131) of adolescents with poorly controlled diabetes (p=0.04) and in 71.7% (95% CI 59.0 - 81.7) of patients ≥16 years of age (p=0.005).Conclusions. Poor glycaemic control, dyslipidaemia and HT are common in diabetic children, putting them at risk of cardiovascular complications in adulthood.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

The Theory of Hyperlipidemic Memory of Type 1 Diabetes

A literature search was conducted to identify publications addressing the early phases of lipid phenotypes in children and adults with either type 1 diabetes or type 2 diabetes. Medline, EMBASE, and Ovid were searched using the following search terms: clinical remission, partial remission, partial clinical remission, honeymoon phase, C-peptide, type 1 or 2 diabetes, children, pediatric type 1 or 2 diabetes, and paediatrics type 1 or 2 diabetes, adults, adult type 1 or type 2 diabetes. Partial clinical remission (PR) of type 1 diabetes (T1D) is characterized by continued endogenous production of insulin and C-peptide following the diagnosis and the introduction of exogenous insulin therapy. PR is associated with improved glycemic control and reduced prevalence of diabetes complications. The theory of hyperglycemic memory was proposed to explain this concept of improved glycemic outcomes in remitters (those who experienced PR) versus non-remitters (those who did not experience PR). However, this theory is incomplete as it does not explain the dichotomy in early lipid phenotypes in T1D based on PR status, which is an understudied area in diabetology and lipidology. To fill this knowledge gap, we propose the Theory of Hyperlipidemic Memory of T1D. This theory is premised on our 5-year research on early post-diagnostic dichotomy in lipid phenotypes between remitters and non-remitters across the lifespan. It provides a more rigorous explanation for the differences in lifelong atherosclerotic cardiovascular disease (ASCVD) risk between remitters and non-remitters. We conducted 4 clinical studies in pediatric and adult subjects with diabetes mellitus to characterize the particulars of the hyperlipidemic memory. In the first investigation, we explored the impact of the presence or absence of PR on lipid parameters in children and adolescents with T1D. In the second, we investigated whether pubertal maturation influenced our findings in T1D; and whether these findings could be replicated in healthy, non-diabetic children and adolescents. In the third, we leveraged our findings from T1D and controls to investigate the mechanisms of early lipid changes in T2D by comparing the earliest lipid phenotype of subjects with type 2 diabetes (T2D) to those of remitters, non-remitters, and controls. In the fourth, we investigated the impact of PR on the earliest lipid phenotypes in adults with T1D and compared these early lipid data to those of T2D subjects and controls. This body of work across the lifespan in children, adolescents, and adults supports the Theory of Hyperlipidemic Memory. This new theory clarifies why PR largely determines the risks for early-phase dyslipidemia, mid-term microvascular disease risk, and long-term ASCVD risk in subjects with T1D.

Typ-1-Diabetes und kardiovaskuläre Risikofaktoren bei Kindern und Jugendlichen

Die langfristigen kardiovaskulären Folgen des Typ-1-Diabetes determinieren die Lebenserwartung betroffener Kinder und Jugendlicher. Risikofaktoren für deren Entwicklung sind eine längere Diabetesdauer bzw. Diabetesmanifestation im frühen Lebensalter, Hypertonie, Rauchen, hoher BMI sowie Fettstoffwechselstörungen. Das Management der kardiovaskulären Risikofaktoren bei Kindern und Jugendlichen mit Typ-1-Diabetes beinhaltet zum einen Screeningsmaßnahmen zur frühzeitigen Aufdeckung der pathologischen Veränderungen und zum anderen eine Lebensstilanpassung im Sinne einer ausgewogenen, normokalorischen Ernährung, regelmäßiger Bewegung sowie ggf. einer medikamentösen lipid- bzw. blutdrucksenkenden Therapie.

Die Leitlinien und Empfehlungen zur standardisierten Erkennung und Behandlung kardiovaskulärer Risikofaktoren bei jungen Menschen mit Typ-1-Diabetes sind bisher uneinheitlich formuliert und werden deshalb nicht immer im klinischen Alltag angewendet bzw. umgesetzt. Dies führt zu einer relevanten Unterversorgung dieser Patientengruppe. Dem gilt es mit mehr Forschungsansätzen und der Entwicklung eines universellen Prozederes zur Diagnostik und Therapie der kardiovaskulären Risikofaktoren entgegenzuwirken.

Mechanisms and early patterns of dyslipidemia in pediatric type 1 and type 2 diabetes

Objectives The is no consensus on the early patterns of lipid-based cardiovascular disease (CVD) risk in youth with either type 1 diabetes (T1D) or type 2 diabetes (T2D). The aim was todetermine the differences in CVD risk, using lipid profiles, in children and adolescents with either T1D or T2D at the time of their first lipid assessment, after stratifying the T1D cohort into remitters and non-remitters based on their honeymoon history. Methods A cross-sectional study of 249 subjects consisting of 73 controls, 53 T2D subjects, and 123 T1D subjects stratified into remitters (n=44), and non-remitters (n=79). Partial clinical remission (PCR) was defined as insulin-dose adjusted HbA1c of ≤9. Pubertal status was determined by Tanner staging. Results After adjusting for age, sex, BMI, race, and pubertal status, T2D patients had significantly higher LDL-C compared to the controls (p=0.022), the remitters (p=0.029), but not the non-remitters (103.1 ± 5.9 mg/dL vs. 91.4 ± 4.2 mg/dL, p=0.49). Similarly, T2D patients had significantly higher non-HDL-C compared to the controls (p=0.006), the remitters (p=0.0002), but not the non-remitters (137.6 ± 7.1 mg/dL vs. 111.71 ± 5.0 mg/dL, p=0.053). Total cholesterol was also significantly higher in T2D patients compared to the controls (p=0.0005), the remitters (p=0.006) but not the non-remitters (183.5 ± 6.6 mg/dL vs. 166.2 ± 4.8 mg/dL, p=0.27). Conclusions Lack of the honeymoon phase in children and adolescents with T1D confers early and significantly increased lipid-based cardiovascular risk to these patients that is similar to the elevated cardiovascular risk seen in T2D.

Dyslipidemia in adolescents and young adults with type 1 and type 2 diabetes: a retrospective analysis

Background

Youth onset type 1 diabetes (T1D) and type 2 diabetes (T2D) is increasing and associated with earlier vascular complications and mortality. Dyslipidemia is an important modifiable cardiovascular (CVD) risk factor that is under-recognized and undertreated in youth with T1D and T2D. Given this, we evaluated the prevalence and associations between lipid concentrations and clinical CVD risk factors in youth with T1D compared to T2D at our large ethnically diverse diabetes center.

Methods

A retrospective chart review was performed, evaluating patients with T1D or T2D seen at least once in clinic from 2015 to 2017, age 10–22 years of age, duration of diabetes at least 6 months on the date of most recent LDL-cholesterol (LDL-C) concentration, and not on statin therapy. We performed independent and multivariable linear regressions of LDL-C and HDL-cholesterol (HDL-C) concentrations.

Results

There were 32.7% with T1D (n = 1701) and 47.7% with T2D (n = 298) with LDL-C above recommend goal (> 100 mg/dL/2.6 mmol/L). Furthermore, there were 9% with T1D and 16.4% with T2D with LDL > 130 mg/dL (> 3.4 mmol/L), who likely met criteria for starting statin therapy. Higher LDL-C and/or lower HDL-C were associated with increased age, diabetes duration, higher HbA1C, female sex, Hispanic ethnicity, obesity, and T2D. After adjusting for these risk factors in a multivariable linear regression model, the association of higher LDL-C and lower HDL-C was higher with T2D than T1D.

Conclusions

This highlights the need for more aggressive dyslipidemia screening and treatment in youth with diabetes, especially T2D. At our institution we have created and instituted quality improvement algorithms to try to address this need.

Lipid profile is associated with treatment regimen in a large cohort of children and adolescents with Type 1 diabetes mellitus: a study from the international SWEET database

AIMS

To examine the effect of pump vs injection therapy on the lipid profile of children with Type 1 diabetes mellitus.

METHODS

A cross-sectional analysis of the lipid profile of children aged ≤ 18 years with Type 1 diabetes mellitus from SWEET, an international diabetes registry, was conducted with a focus on the effect of treatment regimen. Dyslipidaemia was defined as LDL cholesterol ≥2.6 mmol/l or non-HDL cholesterol ≥3.1 mmol/l. LDL and non-HDL cholesterol values among 14 290 children (52% boys, 51% receiving pump therapy) from 60 SWEET centres were analysed by linear and logistic regression analysis adjusted for sex, age, diabetes duration, HbA_1c and BMI-standard deviation score group, region, and common interactions between age, sex, HbA_1c and BMI.

RESULTS

This study confirmed the established associations of increased lipids with female sex, age, diabetes duration, HbA_1c and BMI. LDL and non-HDL cholesterol levels were lower in the pump therapy group compared to the injection therapy group [LDL cholesterol: injection therapy 2.44 mmol/l (95% CI 2.42 to 2.46) vs pump therapy 2.39 mmol/l (95% CI 2.37-2.41), P<0.001; non-HDL cholesterol: injection therapy 2.88 mmol/l (95% CI 2.86 to 2.90) vs pump therapy 2.80 mmol/l (95% CI 2.78-2.82), both P<0.0001]. Similarly, the odds ratios for LDL cholesterol ≥2.6 mmol/l [0.89 (95% CI 0.82-0.97)] and non-HDL cholesterol ≥3.1 mmol/l [0.85 (0.78 to 0.93)] were significantly lower in the pump therapy group, even after all adjustments.

CONCLUSIONS

Our results indicate that pump therapy is associated with a better lipid profile.

Predictive factors of non-HDL cholesterol in children and adolescents with type 1 diabetes mellitius: A cross-sectional study

AIMS

To assess predictors of non-HDL cholesterol in children and adolescents with T1DM.

METHODS

A cross-sectional study of 120 children and adolescents aged 7-16 with T1DM, but without any other chronic morbidities, at a referral outpatient clinic for the treatment of diabetes in Rio de Janeiro, Brazil. Socio-demographic, anthropometric, dietary, and clinical factors were assessed, which included measurements of serum lipids and glycated hemoglobin (HbA1c). Food intake was assessed by 24-h dietary recall. Multiple linear regression was adopted in the analysis.

RESULTS

The mean age of of the subjects was 11.74 ± 2.88 years, 53.3% were female, and the mean duration of T1DM was 6.68 ± 3.33 years. The mean energy intake from carbohydrates, proteins, and lipids was 51.98% (±9.20), 21.43% (±6.13), and 26.57% (±9.98), respectively. The energy intake from processed and ultra-processed foods represented 40.79% of total energy intake. The predictors of non-HDL cholesterol were: HbA1c (%) (p = 0.000, β = 8.5, CI: 4.8-12.1), duration of T1DM (p = 0.000, β = 2.8, CI: 1.3-4.3), and sex (p = 0.032, β = 10.1, CI: 0.9-19.4).

CONCLUSION

Glycemic control was the major modifiable predictor of non-HDL cholesterol concentrations, a significant indicator of cardiovascular risk.

Losing Track of Lipids in Children and Adolescents with Type 1 Diabetes: Towards Individualized Patient Care

AIM

To assess 1) the prevalence of children and adolescents with type 1 diabetes (T1D) changing from low-risk into borderline-high-risk lipid levels or from borderline-high-risk into high-risk lipid levels ('lose track of lipids') and 2) the power of a risk score including the determinants HbA1c, body mass index (BMI), gender, age, diabetes duration and ethnicity in predicting which patients lose track of lipids.

METHODS

651 children and adolescents with T1D were included in this longitudinal retrospective cohort study. Lipid dynamics and the impact of the risk score on losing track of lipids were evaluated. Kaplan-Meier analysis was used to estimate screening intervals.

RESULTS

31-43% percent of the patients had lost track of one or more lipids at the next lipid measurement. This happened more frequently in patients with a low-risk lipid level at start. Depending on the lipid parameter, 5% of patients with low-risk lipid levels lost track of lipids after 13-23 months. The risk score based on concomitant information on the determinants was moderately able to predict which patients would lose track of lipids on the short term.

CONCLUSIONS

A considerable number of children and adolescents with T1D loses track of lipids and does so within a 2-year screening interval. The predictive power of a risk score including age, BMI, gender, HbA1c, diabetes duration and ethnicity is only moderate. Future research should focus on another approach to the determinants used in this study or other determinants predictive of losing track of lipids on the short term.

Achievement of metabolic control among children and adolescents with type 1 diabetes in Spain

AIMS

To assess metabolic control in a paediatric T1D population in Spain and analyse the rate of severe acute decompensations and chronic complications.

METHODS

Data from patients treated at eight paediatric diabetes units with experienced diabetes teams between June and December 2014 were analysed in an observational prospective study. Variables included: age, sex, diabetes duration, number of follow-up visits/year, anthropometrical data, insulin treatment modalities, mean annual HbA1c and the prevalence of acute and chronic complications. SPSS statistics 21.0 was used.

RESULTS

A total of 853 patients (49.7% female) with a mean age of 12.1 ± 3.7 years were included. Anthropometric data were normal. Mean diabetes duration was 8 ± 3.4 years. Mean outpatient follow-up was 4.7 ± 0.04 visits/year. Twenty-five per cent were on continuous subcutaneous insulin infusion (CSII). Mean HbA1c was 7.3 ± 1% (56 ± 8 mmol/mol) and 66.6% had HbA1c < 7.5% (58 mmol/mol). HbA1c value correlated negatively with age at onset and positively with years of diabetes, number of visits/year and current age (F = 7.06; p = 0.01). Patients on CSII (n = 213) were younger, attended the outpatient clinic more frequently, were diagnosed earlier, had better metabolic control and had presented more severe hypoglycaemic episodes the previous year. The rate of severe decompensation (episodes/100 patients/year) was ketoacidosis 1.5 and severe hypoglycaemia 4.5. The prevalence of chronic complications was very low.

CONCLUSIONS

Our data describe the good compliance of paediatric T1D patients treated at eight paediatric units in Spain following international standards of metabolic control.

Predictors of Dyslipidemia Over Time in Youth With Type 1 Diabetes: For the SEARCH for Diabetes in Youth Study

OBJECTIVE

Understanding the risk factors associated with progression and regression of dyslipidemia in youth with type 1 diabetes may guide treatments.

RESEARCH DESIGN AND METHODS

We studied 1,478 youth with type 1 diabetes (age 10.8 ± 3.9 years, 50% male, 77% non-Hispanic white, not on lipid-lowering medications) at baseline and at a mean follow-up of 7.1 ± 1.9 years in the SEARCH for Diabetes in Youth (SEARCH) study. Progression to dyslipidemia was defined as normal lipid concentrations at baseline and abnormal at follow-up (non-HDL-cholesterol [C] >130 mg/dL or HDL-C <35 mg/dL). Regression was defined as abnormal lipids at baseline and normal at follow-up. Multivariable logistic regression was used to evaluate factors associated with progression and regression compared with stable normal and stable abnormal, respectively. An area under the curve (AUC) variable was used for the time-varying covariates A1C and waist-to-height ratio (WHtR).

RESULTS

Non-HDL-C progressed, regressed, was stable normal, and stable abnormal in 19%, 5%, 69%, and 7% of youth with type 1 diabetes, respectively. Corresponding percentages for HDL-C were 3%, 3%, 94%, and 1%, respectively. Factors associated with non-HDL-C progression were higher A1C AUC and higher WHtR AUC in males. Non-HDL-C regression was associated with lower WHtR AUC, and HDL-C progression was associated with male sex and higher WHtR AUC. HDL-C regression was not modeled due to small numbers.

CONCLUSIONS

A1C and WHtR are modifiable risk factors associated with change in dyslipidemia over time in youth with type 1 diabetes.

Predictors of Increased Carotid Intima-Media Thickness in Youth With Type 1 Diabetes: The SEARCH CVD Study

OBJECTIVE

Youth with type 1 diabetes have worse cardiovascular (CV) risk factors and higher carotid intima-media thickness (IMT) than their peers without diabetes. Whether the burden of CV risk factors over time is associated with carotid IMT at follow-up in youth with type 1 diabetes is not known.

RESEARCH DESIGN AND METHODS

Two hundred ninety-eight youth with type 1 diabetes (mean age 13.3 ± 2.9 years, 87.6% non-Hispanic white, 53.7% male) had two study visits 5 years apart. CV risk factors, including BMI, lipids, blood pressure, hemoglobin A(1c), and smoking status, were assessed at both visits, and carotid IMT was measured at follow-up using B-mode ultrasonography. Linear regression models with an area under the curve measurement that incorporated the baseline and follow-up CV risk factors were used to evaluate the relationship with carotid IMT at follow-up.

RESULTS

All CV risk factors worsened significantly over time (except LDL cholesterol) (P < 0.05). From baseline to follow-up, the number of abnormal CV risk factors also increased (P < 0.05). Predictors of carotid IMT were older age, male sex, and higher BMI z score area under the curve (all P < 0.05).

CONCLUSIONS

The CV risk factor burden increases over time in youth with type 1 diabetes. BMI z score was the only modifiable CV risk factor that predicted carotid IMT. This study highlights the critical need to better understand the risk factors that influence carotid IMT early in the course of type 1 diabetes.

Lipid changes and their relationship with vitamin D levels in children under 18 years with type 1 diabetes

OBJECTIVE

To analyze lipid changes and their relationship with 25-hydroxy vitamin D3 (25-OH-D) levels in patients under 18 years old with type 1 diabetes mellitus (T1DM).

MATERIAL AND METHODS

A cross-sectional, descriptive study. Patients under 18 years with T1DM were enrolled by consecutive, nonrandomized sampling. Data collected included sex, age, pubertal stage, time since T1DM onset, weight, height, body mass index (BMI), waist circumference, glycosylated hemoglobin (HbA1c), 25-OH-D, total cholesterol (TC), LDL cholesterol (LDL-C), HDL cholesterol (HDL-C), and triglycerides (TG). Results were stratified by sex, age, and pubertal stage. Data were analyzed using SPSS(®).

RESULTS

Ninety patients with a mean age of 11.7 ± 3.6 years (51.1% males) and mean HbA1c levels of 7.5 ± 1.3% were enrolled. Of these, 26.6% had 25-OH-D levels<20 ng/mL and 13.3% 25-OH-D levels ≤ 15 ng/mL. No differences were found in 25-OH-D between patients with overweight or obesity and the rest. HDL-C levels<40 ng/mL were found in 1.1%, 34.4% had LDL-C levels ≥ 100 mg/dL, and 2.2% had TG levels ≥ 150 mg/dL. Patients with 25-OH-D<20 ng/mL had higher TG levels than the rest (76.80 ± 45.62 vs 57.55 ± 26.08; P=.04) in the multivariate analysis controlled for BMI, waist circumference, and HbA1c. A correlation was found between 25-OH-D and TG levels (-0.230; P=.029).

CONCLUSIONS

Patients in our population with vitamin D deficiency had higher TG levels. Long-term follow-up should be performed to understand the potential impact of such levels on diabetes-related complications.

Predictors of screening for hyperlipidemia in an urban pediatric tertiary care center

INTRODUCTION

It is unknown how the conflicting recommendations of the American Academy of Pediatrics and the US Preventive Services Task Force on pediatric hyperlipidemia affect screening.

OBJECTIVES

(a) Identify clinical predictors for screening for hyperlipidemia, (b) assess the adherence to the 2008 American Academy of Pediatrics guidelines, and (c) determine the efficacy of reminder cards in increasing the adherence to the aforementioned guidelines.

METHODS

Retrospective chart review in the resident, attending, and adolescent medicine clinics during a 3-month period. Reminder cards on each patient chart outlining guidelines for lipid screening for the same clinics were inserted and prospectively assessed for adherence during the following 3 months.

RESULTS

Older age and higher body mass index increased likelihood (odds ratio = 1.2 and 12.7, respectively) for lipid screening. Reminder cards improved adherence in the resident clinic only (χ2 P = .016).

CONCLUSIONS

Age and body mass index were the most significant predictors for lipid screening. Reminder cards modestly improved adherence among resident physicians.

Algorithm-based cholesterol monitoring in children with type 1 diabetes

OBJECTIVE

To facilitate child-specific and diabetes-related cholesterol control, we developed a monitoring algorithm derived from population-based reference values.

STUDY DESIGN

Low-density lipoprotein (LDL)-, non-high-density lipoprotein (HDL)-, and HDL cholesterol percentile values were calculated for children with type 1 diabetes (T1D) and their peers without T1D within algorithm-based categories of sex, age: 1-10 vs >10-<18 years, body mass index: <90th vs ≥90th percentile, and hemoglobin A1c <6%, 6%-<7.5%, 7.5%-9%, >9%. Analyses included 26 147 patients sampled from a German/Austrian population-based registry for T1D (Diabetes Documentation and Quality Management System) and 14 057 peers without diabetes participating in the national Health Interview and Examination Survey for Children and Adolescents in Germany.

RESULTS

Reference percentile values for cholesterol were derived as a diagnostic algorithm aimed at supporting long-term cholesterol control. Taking account of a patient's sex, age-group, weight-, and hemoglobin A1c-category, the flowcharts of the algorithm developed separately for LDL-, non-HDL-, and HDL cholesterol allow comparing his/her cholesterol levels with population-based reference percentile values of peers without T1D.

CONCLUSIONS

The population-based algorithmic approach applied to LDL-, non-HDL-, and HDL cholesterol allows referencing children with T1D with regard to their peers without T1D and, if necessary, suggests corrections of glycemic control to optimize long-term cholesterol levels.

Non-HDL-cholesterol in an adolescent diabetes population

BACKGROUND

Screening for dyslipidemia poses some challenges. Nonfasting lipid profiles frequently have elevated triglycerides. In addition, in the standard lipid profile, low-density lipoprotein (LDL) cholesterol is a calculated value rather than a direct measurement and is triglyceride dependent. Non-high-density lipoprotein cholesterol (non-HDL-C) is an alternative method to assess for dyslipidemia and provides a single estimate of all atherogenic apolipoprotein B-containing lipoproteins.

OBJECTIVE

To calculate the non-HDL-C in adolescents with diabetes and to evaluate risk factors associated with an elevated non-HDL-C and to compare the prevalence of dyslipidemia, defined by non-HDL-C, with the prevalence of dyslipidemia defined by LDL cholesterol in the SEARCH study.

METHODS

Data were collected from 502 adolescent patients with diabetes and analyzed. Non-HDL-C was calculated and levels were categorized into normal, borderline, and high based on the National Cholesterol Education Program.

RESULTS

Lipid profile was performed in 370 patients, 92% of whom had type 1 diabetes. In the 339 subjects with type 1 diabetes, mean hemoglobin A1c (HbA1c) of those with normal non-HDL-C (8.6%) was significantly lower than the HbA1c of those with high non-HDL-C (9.6%) (P = .005). Subjects with normal non-HDL-C had a lower body mass index (BMI) z-score (0.4 ± 0.8) than the group with borderline and high non-HDL-C (0.75 ± 0.9%), P = .002. In the 31 subjects with type 2 diabetes, the mean HbA1c of those with normal non-HDL-C (8.1%) and those with borderline non-HDL-C (7.0%) was significantly lower than the mean HbA1c of those with high non-HDL-C (11.8%) (P = .04, and P = .009, respectively). In addition, the subjects with normal non-HDL-C had a lower BMI z-score (1.3 ± 1.3) than the group with borderline and high non-HDL-C (2.2 ± 0.6%), P = .03. The prevalence of dyslipidemia using non-HDL-C was similar to prevalence rates using LDL-C in the SEARCH study.

CONCLUSIONS

In adolescents with diabetes, non-HDL-C is increased with poorer diabetes control and higher BMI. It appears to be a superior nonfasting lipid screening test for adolescents with diabetes that can be readily calculated on a randomly obtained rather than fasting sample.

Prevalence of cardiovascular risk factors in children and adolescents with type 1 diabetes in Austria

Mortality of cardiovascular diseases in patients with type 1 diabetes is increased 2- to 20-fold compared to non-diabetic individuals. In young adults with type 1 diabetes, cardiovascular events are more often the cause of premature death than nephropathy. The aim of this study was to evaluate the prevalence and extent of cardiovascular risk factors in children and adolescents with type 1 diabetes in Austria. In a cross sectional study data of children with type 1 diabetes <18 years of age treated at the Children's department of the University Hospitals of Vienna and Graz were collected. We recorded body mass index, waist circumference, blood pressure, HbA1c, triglycerides, total cholesterol, high-density lipoprotein cholesterol and low-density lipoprotein cholesterol according to age, sex, age at manifestation, diabetes duration, and insulin requirement. From 264 patients (49.4% male) complete data were available. Of all patients, 76.1% had one or more risk factors, 20.8% had two or more, 10.2% had three or more, and 4.9% had four or more risk factors. Insufficient glycemic control was the most frequent risk factor, present in 60.6% of our patients, followed by elevated triglycerides (22.7%) and increased body mass index (20.1%). Higher prevalence of risk factors was correlated with increasing age, diabetes duration, HbA1c, and insulin requirement. In conclusion, children and adolescents with type 1 diabetes have a much higher prevalence of cardiovascular risk factors compared to non-diabetic individuals. To prevent future cardiovascular events, achieving the best possible glycemic control, early detection of further risk factors, and adequate intervention are highly important.

Glycemic control in Iranian children with type 1 diabetes mellitus: effect of gender

OBJECTIVES

To evaluate the effect of gender on glycemic control, diabetic complications and associated abnormalities in patients with type 1 diabetes mellitus (T1DM).

METHODS

In the present cross-sectional study, patients with T1DM referred to endocrinology clinic in children's hospital medical center in Tehran from March 2005 through March 2007 were enrolled. For each patient a questionnaire was filled. Finally, effect of gender on glycemic control was analyzed.

RESULTS

Male patients did self monitoring of blood glucose significantly more than female patients. Mean HbA1c which is used as an indicator of glycemic control, insulin dose per kg of body weight and also frequency of diabetic ketoacidosis (DKA), height problems and dyslipidemia were significantly higher in female patients.

CONCLUSIONS

Because of worse glycemic control and higher incidence of DKA, dyslipidemia and height problems in female patients, focus on glycemic control of female patients according to local guidelines on clinical management of T1DM is required.

A longitudinal assessment of lipids in youth with type 1 diabetes

BACKGROUND

Type 1 diabetes and dyslipidemia are known risk factors for cardiovascular disease (CVD), but the relationship between lipid levels in youth with type 1 diabetes and future CVD remains unknown.

OBJECTIVE

To characterize lipid levels and CVD risk factors over time in youth with type 1 diabetes.

SUBJECTS

The study included adolescents with type 1 diabetes (12-25 yr) with a minimum of 3-yr follow-up.

METHODS

A longitudinal prospective, observational study of 46 youth with type 1 diabetes was performed. Fasting lipid profiles, A1C, and body mass index (BMI) were measured every 6 months for at least 3 yr (median 4.2 yr). Low-density lipoprotein (LDL)-cholesterol, total cholesterol (TC), and triglycerides (TG) were divided into categorical variables.

RESULTS

At baseline, median age was 14.3 yr, mean diabetes duration was 6.4 ± 3.8 yr, mean A1C was 8.1 ± 1.0%, and median BMI z-score was 0.92. Fifty percent of subjects had LDL levels ≤ 100 mg/dL (≤ 2.6 mmol/L) at study onset. After adjusting for confounding factors, increasing BMI z-score [β = 0.2, 95% confidence interval (CI ) = 0.03-0.38, p = 0.03] and increasing A1C (β = 0.18, 95% CI = 0.08-0.29, p = 0.001) were associated with increasing LDL category over time. Non-Hispanic ethnicity (β = 0.45, 95% CI = 0.12-0.79, p = 0.008) and family history of stroke (β = 0.38, 95% CI = 0.04-0.72, p = 0.03) were also associated with increasing LDL category. Age, diabetes duration, and tobacco exposure were not related to change in LDL. Increasing A1C was associated with increases in TG (β = 18.1, 95% CI = 2.3-33.9, p = 0.03), TC (β = 20.3, 95% CI = 9.0-31.5, p < 0.0001), and LDL (β = 13.4, 95% CI = 3.17- 23.6, p = 0.01).

CONCLUSION

Glycemic control and BMI are modifiable risk factors for dyslipidemia in youth with type 1 diabetes.

Oxidative damage is present in the fatal brain edema of diabetic ketoacidosis

Oxidative stress is implicated as a pathogenic factor in a spectrum of chronic diseases, notably, neurodegenerative disease. Noteworthy in this regard is that type 1 diabetes mellitus (T1DM) results in oxidative stress, leading to systemic complications of T1DM. We hypothesized that oxidative stress associated with diabetic ketoacidosis (DKA) of T1DM might have measurable brain sequelae. Consistent with this hypothesis are neurohistology and neuroradiologic studies of T1DM that suggest oxidative insults are involved in the chronic complications of diabetic encephalopathy. To further address the role of oxidative stress in an acute setting, specifically in fatal brain edema (BE) associated with DKA, we studied neuronal localization and levels of oxidative stress markers reported to be increased in other neurodegenerative conditions. We demonstrated increased levels of 8-hydroxyguanosine (8OHG), 4-hydroxynonenal (HNE), and heme oxygenase-1 (HO-1) in the pyramidal neurons of the hippocampus of DKA BE in comparison to controls. However, in the cerebellum, only 8OHG was increased in the Purkinje cells and other cells of the molecular layer. These results indicate a role for oxidative stress in the pathogenesis of T1DM encephalopathy.