Cardiovascular health in adolescents with type 1 diabetes: the SEARCH CVD study

The Mediterranean Diet for Adolescents with Type 1 Diabetes: A Prospective Interventional Study

The Mediterranean diet (MED) is highly recommended. Medical nutrition therapy is the cornerstone of diabetes treatment. The primary outcome was to evaluate the change in micronutrient intake of youth with type 1 diabetes before and after a 6-month MED intervention; we also assessed adherence and glycemic control. Twenty adolescents, median age 18 years (interquartile range: 15.5-21), median diabetes duration 9 years (7-14), using continuous glucose monitoring devices, received personalized diet regimes based on MED. At 6 months post-intervention, the caloric intake remained unchanged; however, the carbohydrate proportion was lower (p = 0.058), and the intakes of some monounsaturated fats increased (p = 0.049). Sodium intake exceeded the recommended daily allowance by 250% (p = 0.653), before and after the intervention. For blood glucose, the percent TIR (time-in-range, 70-180 mg/dL) improved from 52% (38-60) to 63% (47-71) (p = 0.047). The total insulin dose decreased marginally, from 0.76 u/kg (0.64-0.97) to 0.72 u/kg (0.61-0.89) (p = 0.067). BMI z-score and waist circumference did not change (p = 0.316 and p = 0.161, respectively). Diastolic blood pressure percentile decreased from 73% (68-88) to 69% (50-79) (p = 0.028), and LDL cholesterol from 114 mg/dL (105-134) to 104 mg/dL (96-124) (p = 0.059). The Israeli Mediterranean diet screener score increased, from 8 (7-11) to 13 points (12-14) (p < 0.001). The MED-based intervention in youth with type 1 diabetes is feasible and leads to improvement in monounsaturated fat intake, TIR, and diastolic blood pressure. Other parameters show no change (caloric intake, BMI, and HbA1c).

Dietary Intake and Physical Activity of Thai Children and Adolescents with Type 1 Diabetes Mellitus

Appropriate dietary intake and physical activity (PA) are essential for glycemic control and optimal growth in youth with type 1 diabetes (T1D). Thus, this study aimed to compare dietary intake and PA between youth with T1D and healthy controls. One hundred Thai youth with T1D and 100 age-matched healthy participants were recruited. A 3-day food record was completed and converted into nutrient intake data. PA data were collected via interview. Participants with T1D had a significantly higher mean ± SD carbohydrate (50.8 ± 6.8% vs. 46.2 ± 7.5%, p < 0.01), lower fat (32.4 ± 5.9% vs. 35.9 ± 6.4%, p < 0.01), and lower protein (16.8 ± 2.6% vs. 17.9 ± 3.5%, p = 0.01) intake compared to controls. Fifty percent of T1D participants and 41% of control participants consumed saturated fat more than recommendations (p = 0.20). Participants with T1D had a higher median (IQR) calcium intake compared to controls (474 (297−700) vs. 328 (167−447) mg/day, p < 0.01). Both groups consumed less fiber and more sodium compared to recommendations. Both groups had inadequate PA. Participants with T1D had significantly less PA compared to controls (25 (13−48) vs. 34 (14−77) minutes/day, p = 0.04). In addition to the need for counseling that promotes consumption of more dietary fiber and calcium and less saturated fat and sodium, the benefits of performing regular exercise need to be emphasized among youth with T1D.

Incident cardiovascular disease by clustering of favourable risk factors in type 1 diabetes: the EURODIAB Prospective Complications Study

AIMS

The aim of this prospective study was to examine CVD risk reduction in type 1 diabetes (1) for people with favourable cardiovascular health metrics and (2) by clustering of these metrics.

METHODS

Data from 2313 participants from the EURODIAB Prospective Complications Study were analysed. All had type 1 diabetes (51% men, mean ± SD age 32 ± 9 years). Seven cardiovascular health metrics were studied-smoking, BMI, physical activity, a diet score, total cholesterol/HDL-cholesterol ratio, combined systolic and diastolic BP and HbA_1c-divided into favourable/less favourable categories. Cox proportional hazards models were used to calculate HRs (95% CIs) of incident CVD for each metric. Clusters were made by scoring each individual by the number of favourable metrics.

RESULTS

A total of 163 people developed incident CVD during a mean ± SD follow-up of 7.2 ± 1.3 years. Participants with more favourable HbA_1c levels of <57 mmol/mol (<7.4%) had a 37% significantly lower CVD risk than those with a less favourable HbA_1c (HR [95% CI] 0.63 [0.44, 0.91]), and participants with a more favourable BP (systolic BP <112 mmHg and diastolic BP <70 mmHg) had a 44% significantly lower CVD risk than participants in the less favourable BP group (HR [95% CI] 0.56 [0.34, 0.92]). There was a dose-response relation with a lower HR observed with greater clustering of more favourable metrics: people with four or more favourable metrics had an HR of 0.37 (95% CI 0.18, 0.76), adjusted for sex and age at diabetes diagnosis, compared with those with no favourable metrics.

CONCLUSIONS/INTERPRETATION

Low HbA_1c and low BP were protective cardiovascular health metrics in our study of people with type 1 diabetes. Targeting all cardiovascular health metrics could be more effective in preventing CVD than targeting single metrics.

Home food access and children's heart healthy dietary intake at home and child care

Background: About 12 million children under 5 years of age attend early care and education centers (ECEs). Child intake at home can be impacted by food insecurity, which is higher among low income, rural, and racially diverse families. Aim: Determine whether greater access to fruits, vegetables, and snacks at home was associated with heart-healthy diet score at home and at ECEs in preschool-age children, and to determine whether there is a difference in heart-healthy diet score between home and ECEs. Methods: Cross-sectional study involving children (3-to-5-year-old, n  =  88) who attended 16 licensed ECEs across Oklahoma. Caregivers completed the Healthy Home Survey and 3-Dinner Dietary recall to report children's home food access and home dinner dietary intake, respectively. Researchers recorded children's ECE lunch consumption using the Dietary Observation for Child Care. Heart-healthy diet score was derived from composite scores for six variables: consumption of fish, fruits, vegetables, sodium, fiber, and sugary drinks. Results: Home access to total fruits and vegetables (16.2  ±  6.3) outnumbered snacks (5.5  ±  3.0). No difference in composite heart-healthy diet score between ECEs (1.50  ±  0.8) and home (1.27  ±  0.9, P  =  0.0851). Children within neither environment met recommendations for most variables (vegetables [18-24%], fruit [6-10%], fish [5-10%], fiber [1%], sodium [22-39%]). No relationship between home food access variables and the heart-healthy diet scores at home or ECEs. Conclusion: Dietary intake of children at home and ECEs does not meet heart-healthy diet score recommendations. Interventions should support preschool aged children from families that are located rurally, low-income, racial minorities, and whose primary caregivers work outside the home.

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.

Association between Ideal Cardiovascular Health and aortic stiffness in Italian adolescents. The MACISTE study

BACKGROUND AND AIMS

Ideal Cardiovascular Health (ICH), defined as optimal levels of cardiovascular (CV) health factors and behaviors, has been reported to be very low in adults and children, with consequent several negative health outcomes and higher CV risk. The present study investigated the burden of ICH among Italian adolescents and its association with carotid-femoral pulse wave velocity (cf-PWV).

METHODS AND RESULTS

387 healthy adolescents (mean age 17.1 ± 1.4 years) attending the "G. Donatelli" High School in Terni, Italy, were evaluated. ICH was assessed through clinical evaluation, laboratory measures and interviewer-administered questionnaires. Cf-PWV was measured by arterial tonometry (SphygmoCor). For each ICH metric, a score of 2 was assigned for ideal levels, 1 for intermediate, and 0 for poor. All subjects showed at least one ICH metric, whereas none showed all ICH 7 metrics. The average number of ICH metrics was 4.3 ± 1.1. The highest rates were observed for fasting blood glucose (98%), whereas an ideal healthy diet was achieved only by 8% of subjects. The Cf-PWV was inversely and linearly associated with the sum of ICH metrics (p = 0.03) and the ICH score (p < 0.01). At the multivariate analysis, the association between ICH score and cf-PWV remained significant after adjustment for age, sex, heart rate, mean arterial pressure and other confounders (p = 0.04).

CONCLUSION

ICH is relatively uncommon among Italian adolescents and inversely related to cf-PWV. Our results showed a detrimental association between CV unhealthy factors and behaviors with increased aortic stiffness, which starts developing at an early stage of the lifespan.

Endothelial impairment evaluation by peripheral arterial tonometry in pediatric endocrinopathies: A narrative review

Endothelial dysfunction (ED) is characterized by an imbalance between vasodilator and vasoconstriction agents. Several pathological conditions clinically diagnosed in childhood and adolescence are characterized by ED and increased risk for early development of microangiopathic and macroangiopathic impairment, in particular type 1 diabetes mellitus (T1DM), T2DM, obesity, metabolic syndromeand pituitary dysfunction associated to various endocrinopathies. More recently insulin resistance following chemotherapy or radiotherapy for tumors, bone marrow transplantation for hematological malignancies (i.e., cancer survivors), or immunosuppressive treatment for solid organ transplantation has been observed. Assessment of ED by means of non-invasive techniques is the gold standard for early ED detection before clinical manifestation. It is aimed to recognize patients at risk and to avoid the development and progression of more serious illnesses. Reactive hyperemia-peripheral artery tonometry is a noninvasive technique to assess peripheral endothelial function by measuring modifications in digital pulse volume during reactive hyperemia, and represents a non-invasive, reproducible and operator-independent tool able to detect precocious ED. This narrative review aimed to provide an overview of the most important papers regarding ED detection by EndoPat 2000 in children and adolescents with different endocrine diseases. A comprehensive search of English language articles was performed in the MEDLINE database without using other search filters except the publication interval between 2005 and 2020.

Longitudinal association between cardiovascular health and arterial stiffness in the Chinese adult population

Objective

Arterial stiffness may be an intermediary biological pathway involved in the association between cardiovascular health (CVH) and cardiovascular disease. We aimed to evaluate the effect of CVH on progression of brachial–ankle pulse wave velocity (baPWV) over approximately 4 years.

Methods

We included 1315 cardiovascular disease-free adults (49±12 years) who had two checkups from 2010 to 2019. CVH metrics (current smoking, body mass index, total cholesterol, blood pressure, and fasting plasma glucose) were assessed at baseline, and the number of ideal CVH metrics and CVH score were calculated. Additionally, baPWV was examined at baseline and follow-up.

Results

Median baPWV increased from 1340 cm/s to 1400 cm/s, with an average annual change in baPWV of 15 cm/s. More ideal CVH metrics and a higher CVH score were associated with lower baseline and follow-up baPWV, and the annual change in baPWV, even after adjustment for confounding variables. Associations between CVH parameters and baseline and follow-up baPWV remained robust in different sex and age subgroups, but they were only able to predict the annual change in baPWV in men and individuals older than 50 years.

Conclusions

Our findings highlight the benefit of a better baseline CVH profile for progression of arterial stiffness.

Cardiovascular disease in young People with Type 1 Diabetes: Search for Cardiovascular Biomarkers

Premature onset of cardiovascular disease is common in people with type 1 diabetes and is relatively understudied in youth. Several reports in adolescents and young adults with diabetes demonstrate evidence of arterial stiffness and cardiac dysfunction, yet critical gaps exist in our current understanding of the temporal progression of cardiac and vascular dysfunction in these youth, and mechanistic investigations with robust pathophysiologic assessment are lacking. This review attempts to summarize relevant cardiovascular studies concerning children, adolescents, and young adults with type 1 diabetes. We focus on imaging-based biomarkers routinely applied to youth and adults that are well-established in their ability to predict adjudicated cardiovascular outcomes, and their relevant physiologic interpretation. Particularly, we focus the attention to 1) cardiac ventricular strain imaging techniques which are known to be predictive of clinical outcomes in patients with heterogenous causes of heart failure, and 2) stiffness in large arteries, a well-established prognostic marker of cardiovascular events. We conclude that there remains an urgent need for sensitive and quantitative biomarkers to define the natural history of cardiac and vascular disease origination and progression in type 1 diabetes, and set the stage for interpreting interventional studies focused on preventing, reversing or slowing disease progression.

Heart Rate Variability and Cardiorespiratory Fitness in Non-Hispanic Black Versus Non-Hispanic White Adolescents With Type 1 Diabetes

BACKGROUND

Evidence indicates that fewer non-Hispanic black versus non-Hispanic white youths with type 1 diabetes are meeting treatment goals for optimal glycemic outcomes, predisposing them to risks for cardiovascular (CV) morbidity and mortality in adulthood.

PURPOSE

We sought to assess the association of sex and race with heart rate variability (HRV) and cardiorespiratory fitness in adolescents with type 1 diabetes. The association between the HRV and cardiorespiratory outcomes with glucose control was also examined.

METHODS

A secondary data analysis of 95 adolescents with type 1 diabetes (n = 66 non-Hispanic white n = 29 non-Hispanic black) was used. Using 24-hour Holter recordings, spectral and time domain measures of HRV were obtained. Cardiorespiratory fitness using a graded exercise test was completed. Descriptive statistics and Pearson correlation coefficients were used to assess associations between glucose control and study outcomes, and general linear models were applied to explore and quantify associations of sex and race with HRV and cardiorespiratory fitness.

RESULTS

Body mass index (mean [standard deviation]) was similar between non-Hispanic black (23.5 [3.9]) and non-Hispanic white (22.7 [3.8]) adolescents. Females and non-Hispanic black adolescents had significantly lower HRV and cardiorespiratory fitness levels. Moderate associations were found between lower HRV and poorer glycemic control (HbA1c). Recent HbA1c was significantly higher in non-Hispanic black (9.7 [1.8]) than non-Hispanic white (8.2 [1.2]).

CONCLUSION

Findings support the importance of early identification of CV health risks in adolescents with type 1 diabetes, particularly for non-Hispanic black adolescents. Interventions focused on overall improvement in glycemic control for adolescents with type 1 diabetes are a priority for minimizing future CV complications.

Cardiometabolic Health and Carotid-Femoral Pulse Wave Velocity in Children: A Systematic Review and Meta-Regression

OBJECTIVE

To identify, in children the normal rate of carotid-femoral pulse wave velocity (cfPWV) progression, and whether presence of cardiometabolic risk factors is associated with cfPWV.

STUDY DESIGN

Electronic databases (PubMed, Google Scholar) were searched from inception to May 2018, for all studies which reported cfPWV in children (<19 years of age). Random effects meta-regression quantified the association between time (years) and cfPWV, and a systematic review was performed to determine whether cardiometabolic risk factors are associated with cfPWV.

RESULTS

Data from 28 articles were eligible for inclusion, including 9 reference value (n = 13 100), 5 cardiovascular risk (n = 5257), 10 metabolic risk (n = 2999), and 8 obesity-focused (n = 8760) studies. Meta-regression findings (9 studies) showed that the increase in cfPWV per year (age) was 0.12 m/second (95% CI, 0.07-0.16 m/second) per year, and when stratified by sex the CIs overlapped. Systematic review findings showed that cardiometabolic risk factors were positively associated with cfPWV, including positive associations with blood pressure, impaired glucose metabolism, and metabolic syndrome. However, obesity was not consistently associated with cfPWV.

CONCLUSIONS

Arterial stiffness in children progresses with age and is associated with cardiometabolic risk factors. Although further longitudinal studies are warranted, the presented reference data will be valuable to epidemiologists tracking children, and to scientists and clinicians prescribing therapies to mitigate risk in a population that is increasingly more vulnerable to cardiovascular disease.

Cardiovascular Risk Reduction in High-Risk Pediatric Patients: A Scientific Statement From the American Heart Association

This scientific statement presents considerations for clinical management regarding the assessment and risk reduction of select pediatric populations at high risk for premature cardiovascular disease, including acquired arteriosclerosis or atherosclerosis. For each topic, the evidence for accelerated acquired coronary artery disease and stroke in childhood and adolescence and the evidence for benefit of interventions in youth will be reviewed. Children and adolescents may be at higher risk for cardiovascular disease because of significant atherosclerotic or arteriosclerotic risk factors, high-risk conditions that promote atherosclerosis, or coronary artery or other cardiac or vascular abnormalities that make the individual more vulnerable to the adverse effects of traditional cardiovascular risk factors. Existing scientific statements and guidelines will be referenced when applicable, and suggestions for risk identification and reduction specific to each setting will be described. This statement is directed toward pediatric cardiologists, primary care providers, and subspecialists who provide clinical care for these young patients. The focus will be on management and justification for management, minimizing information on pathophysiology and epidemiology.

Inflammation and acute traffic-related air pollution exposures among a cohort of youth with type 1 diabetes

BACKGROUND

Evidence remains equivocal regarding the association of inflammation, a precursor to cardiovascular disease, and acute exposures to ambient air pollution from traffic-related particulate matter. Though youth with type 1 diabetes are at higher risk for cardiovascular disease, the relationship of inflammation and ambient air pollution exposures in this population has received little attention.

OBJECTIVES

Using five geographically diverse US sites from the racially- and ethnically-diverse SEARCH for Diabetes in Youth Cohort, we examined the relationship of acute exposures to PM2.5 mass, Atmospheric Dispersion Modeling System (ADMS)-Roads traffic-related PM concentrations near roadways, and elemental carbon (EC) with biomarkers of inflammation including interleukin-6 (IL-6), c-reactive protein (hs-CRP) and fibrinogen.

METHODS

Baseline questionnaires and blood were obtained at a study visit. Using a spatio-temporal modeling approach, pollutant exposures for 7 days prior to blood draw were assigned to residential addresses. Linear mixed models for each outcome and exposure were adjusted for demographic and lifestyle factors identified a priori.

RESULTS

Among the 2566 participants with complete data, fully-adjusted models showed positive associations of EC average week exposures with IL-6 and hs-CRP, and PM2.5 mass exposures on lag day 3 with IL-6 levels. Comparing the 25th and 75th percentiles of average week EC exposures resulted in 8.3% higher IL-6 (95%CI: 2.7%,14.3%) and 9.8% higher hs-CRP (95%CI: 2.4%,17.7%). We observed some evidence of effect modification for the relationships of PM2.5 mass exposures with hs-CRP by gender and with IL-6 by race/ethnicity.

CONCLUSIONS

Indicators of inflammation were associated with estimated traffic-related air pollutant exposures in this study population of youth with type 1 diabetes. Thus youth with type 1 diabetes may be at increased risk of air pollution-related inflammation. These findings and the racial/ethnic and gender differences observed deserve further exploration.

Trajectories of hemoglobin A1c and body mass index z-score over four decades among 2 to 18 year olds with type 1 diabetes

OBJECTIVES

To determine trajectories of glycemic control and body mass index (BMI) z-score in a large pediatric sample with type 1 diabetes (T1D) over a 38-year period, and to evaluate sex differences and temporal changes in the prevalence of these trajectories.

METHODS

We conducted a longitudinal, retrospective study of 7002 2 to 18 year olds with T1D followed between 1978 and 2016 at a single center. Group-based modeling was used to identify trajectories for hemoglobin A1c (HbA1c) and BMI z-score. Multinomial logistic regression identified predictors of membership to less favorable glycemic trajectories.

RESULTS

Group-based modeling yielded 5 HbA1c trajectories. A total of 86% of the sample fell within 3 trajectories that were largely stable across childhood and adolescence, and 14% fell within 2 trajectories characterized by marked deterioration beginning in pre-adolescence. Girls were more likely to be in the HbA1c trajectory with the highest starting HbA1c and significant deterioration during adolescence, and in the highest two BMI z-score trajectories. Patients with non-white race had the highest odds of belonging to a less favorable HbA1c trajectory. Prevalence of the high stable HbA1c trajectory decreased and prevalence of the low stable HbA1c trajectory increased over the study period.

CONCLUSIONS

A minority of youth with T1D experienced deterioration of glycemic control during adolescence. Girls were more likely to belong to the worst HbA1c trajectory and to BMI z-score trajectories in the overweight/obese range, which may increase cardiometabolic risk. Addressing racial/ethnic disparities in glycemic control should remain a priority. Advances in T1D management correlated with favorable shifts in HbA1c trajectory prevalence.

Burden of Cardiovascular Risk Factors Over Time and Arterial Stiffness in Youth With Type 1 Diabetes Mellitus: The SEARCH for Diabetes in Youth Study

Background The incidence of type 1 diabetes mellitus (T1DM) in children is increasing, resulting in higher burden of cardiovascular diseases due to diabetes mellitus-related vascular dysfunction. Methods and Results We examined cardiovascular risk factors ( CVRF s) and arterial parameters in 1809 youth with T1DM. Demographics, anthropometrics, blood pressure, and laboratory data were collected at T1DM onset and 5 years later. Pulse wave velocity and augmentation index were collected with tonometry. ANOVA or chi-square tests were used to test for differences in measures of arterial parameters by CVRF . Area under the curve of CVRF s was entered in general linear models to explore determinants of accelerate vascular aging. Participants at the time of arterial measurement were 17.6±4.5 years old, 50% female, 76% non-Hispanic white, and duration of T1DM was 7.8±1.9 years. Glycemic control was poor (glycated hemoglobin, 9.1±1.8%). All arterial parameters were higher in participants with glycated hemoglobin ≥9% and pulse wave velocity was higher with lower insulin sensitivity or longer duration of diabetes mellitus. Differences in arterial parameters were found by sex, age, and presence of obesity, hypertension, or dyslipidemia. In multivariable models, higher glycated hemoglobin, lower insulin sensitivity, body mass index, blood pressure, and lipid areas under the curve were associated with accelerated vascular aging. Conclusions In young people with T1DM, persistent poor glycemic control and higher levels of traditional CVRF s are independently associated with arterial aging. Improving glycemic control and interventions to lower CVRF s may prevent future cardiovascular events in young individuals with T1DM.

Arterial stiffness as a measure of cardiovascular risk in obese adolescents and adolescents with diabetes type 1

Background Cardiovascular disease (CVD) is the end result of vascular aging and atherosclerosis, having its origins in childhood. The aim of our study was to compare arterial stiffness (AS) and intima-media thickness (IMT) as markers of an early vascular damage between obese adolescents, adolescents with diabetes type 1 (T1D) and lean control subjects. Methods We analyzed AS and IMT in 68 obese adolescents (13.27±2.31 years), 42 adolescents with T1D (14.95±2.35 years) lasting over 5 years and 38 controls (15.02±1.94 years). AS (measured by pulse wave velocity [PWV], arterial compliance [AC] and β-stiffness) and IMT were assessed using an e-tracking ultrasound method. Results A significant difference between the groups was found for AC (p=0.022) and PWV (p=0.010), with the lowest compliance and higher velocities in T1D patients. When corrected for age, the difference in AC among the groups did not reach a statistical difference (p=0.059). Correlation analysis in the obese adolescents showed lower AC in females (p=0.041), with higher systolic blood pressure (SBP) (p=0.032). In T1D adolescents, disease duration was the strongest determinant of AS (AC p=0.028, β p=0.029 and PWV p=0.003), followed by body mass index (BMI; PWV p=0.008; β p=0.033), SBP (AC p<0.001; PWV p=0.023), diastolic BP (AC p=0.049; PWV p=0.048) and HbA1c (PWV p=0.048). No significant correlations were found for AS measures or IMT with sex, age, BMI, Tanner stage or BP levels in controls. Conclusions Early vascular damage is more pronounced in T1D adolescents than in obese or lean adolescents, which may emphasize the impact of hyperglycemia as a major threat for cardiovascular health.

Cross-sectional associations between Ideal Cardiovascular Health scores and vascular phenotypes in 11- to 12-year-olds and their parents: The Longitudinal Study of Australian Children

BACKGROUND

Understanding early-life relationships between the Ideal Cardiovascular Health (ICVH) score and vascular phenotypes could inform likely effectiveness and timing of cardiovascular disease prevention strategies. We aimed to describe associations between ICVH scores and vascular phenotypes in 11- to 12-year-old children and their parents.

METHODS AND RESULTS

Cross-sectional ICVH scores (range 0-7, higher indicating better health), derived by summing dichotomized metrics for cholesterol, glucose, blood pressure (BP), body mass index (BMI), diet, physical activity and smoking, were constructed for 1235 adults (89% female, mean age 43 years) and 1028 children (48% female, 12 years). The median scores were 4 and 5 for adults and children respectively. Child ICVH scores were associated with parent scores (0.18 higher child score per additional point in parent's score, 95% CI 0.12 to 0.22, P < 0.001). Each additional point in the adult ICVH score was associated with slower carotid-femoral pulse wave velocity (PWV, -0.32 m/s, 95% CI -0.37 to -0.27), greater carotid elasticity (0.017%/mm Hg, 95% CI 0.014 to 0.020) and reduced carotid intima-media thickness (IMT, -7.3 μm, 95% CI -12.0 to -2.5). An additional point in the child score was associated with functional phenotypes (PWV -0.07 m/s, 95% CI -0.11 to -0.03; carotid elasticity 0.009%/mm Hg, 95% CI 0.004 to 0.015) but not structural phenotypes (IMT -1.8 μm, 95% CI -5.2 to 1.5).

CONCLUSION

Few Australian children and even fewer parents have ideal cardiovascular health. Lower ICVH scores were associated with adverse adult vascular phenotypes and adverse child vascular function. Family-based interventions optimizing ICVH metrics may delay onset and progression of subclinical atherosclerosis and later cardiovascular disease.

Feasibility of Ideal Cardiovascular Health Evaluation in a Pediatric Clinic Setting

The feasibility of “point-of-care” screening for ideal cardiovascular health was explored in a pediatric specialty clinic setting. Children and adolescents aged 9–18 years (n=91) with treated and stabilized diseases were recruited at a pediatric endocrinology clinic. A table-top device was used to assay fingerstick samples for non-HDL cholesterol (non-HDL-C), which was used to divide participants into two groups based on the non-HDL-C threshold for comparison of the remaining metrics between groups. A significant number of children had low scores, and score frequency distribution was similar to larger retrospective studies, with few participants achieving none or all of the health metrics. Healthy diet was the metric least often achieved. Those with a non-HDL-C above the ideal threshold of 3.1 mmol/L (120 mg/dl) had a higher BMI percentile (p<0.01) and diastolic blood pressure percentile (p<0.05). We conclude that pediatric risk factor screening and scoring can be performed in a specialty clinic with meaningful cardiovascular health scores for patients and providers. Association of abnormal “point-of care” non-HDL-C levels with elevated BMI and blood pressure supports evidence for risk factor clustering and use of the ideal health construct in pediatric clinic settings.

Cardiac and Vascular Target Organ Damage in Pediatric Hypertension

Atherosclerosis begins in youth and is associated with the presence of numerous modifiable cardiovascular (CV) risk factors, including hypertension. Pediatric hypertension has increased in prevalence since the 1980s but has plateaued in recent years. Elevated blood pressure levels are associated with impairments to cardiac and vascular structure and both systolic and diastolic function. Blood pressure-related increases in left ventricular mass (LVM) and abnormalities in cardiac function are associated with hard CV events in adulthood. In addition to cardiac changes, key vascular changes occur in hypertensive youth and adults. These include thickening of the arteries, increased arterial stiffness, and decreased endothelial function. This review summarizes the epidemiologic burden of pediatric hypertension, its associations with target organ damage (TOD) of the cardiac and vascular systems, and the impact of these adverse CV changes on morbidity and mortality in adulthood.

Dietary sodium intake relates to vascular health in children with type 1 diabetes

BACKGROUND AND OBJECTIVE

Children with type 1 diabetes (T1D) have vascular dysfunction and frequently struggle to adhere to dietary recommendations. Limited data exist for the vascular consequences of poor diet quality in children. We aimed to evaluate the association between dietary components and vascular function in children with T1D.

METHODS

Cross-sectional study including 90 children (13.6 [3.5] years, 41 boys) with T1D. They had evaluation of dietary micro and macronutrients (Australian Child and Adolescent Eating Survey), vascular endothelial and smooth muscle function (flow-mediated dilatation and glyceryl trinitrate mediated dilatation [GTN], respectively), clinical and biochemical variables.

RESULTS

Children had a sodium intake of 3.013 (0.76) (mean [SD]) g/day. Vascular smooth muscle dysfunction, as measured by GTN, related to higher daily sodium intake (r = -0.31, P = .003), independent of the inverse relationships between GTN and total energy (r = -0.30, P = .005) and fat intake (r = -0.28, P = .007). Multiregression model showed that an increase in 1 g of daily sodium intake was independently associated with a deterioration of 3 percentage units in GTN (95% CI -4.3, -0.9; P = .003). There was an association between sodium intake and systolic blood pressure after adjustment for age and gender (regression coefficient 2.4; 95% CI 0.5, 4.3; P = .01).

CONCLUSIONS

High dietary sodium intake in children with T1D is common and relates to vascular dysfunction, independently of other dietary intake, blood pressure, and glycemic control.

Whole Egg Consumption Exerts a Nephroprotective Effect in an Acute Rodent Model of Type 1 Diabetes

Nephropathy is a well-characterized complication of type 1 diabetes (T1D), resulting in proteinuria and urinary loss of micronutrients. We previously found that a whole egg-based diet maintained vitamin D balance in type 2 diabetic rats despite excessive urinary losses due to nephropathy. The goal of this study was to investigate the impact of whole egg consumption in T1D rats. Sprague-Dawley rats were randomly assigned to T1D or nondiabetic control groups and fed a casein or whole egg-based diet for 32 days. On day 26, two-thirds of the rats received a streptozotocin injection to induce T1D. Whole egg consumption attenuated polyuria, proteinuria, and renal hypertrophy in T1D rats. These data suggest that dietary intervention with whole egg may offer renal protection in T1D.

Ideal cardiovascular health and liver enzyme levels in European adolescents; the HELENA study

There is an increasing interest for the role of liver enzymes as predictors of non-liver-related morbidity and mortality. The American Heart Association (AHA) described the ideal cardiovascular health concept as a score of seven cardiovascular health behaviors and factors that can be used to monitor and predict ideal cardiovascular health over time. This study aimed to examine the association of the ideal cardiovascular health (ICH), as defined by the AHA, with liver enzyme levels in European adolescents. A total of 637 adolescents (54.6% females), aged 14.6 ± 1.2 years from nine European countries participated in this cross-sectional study. Blood levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), and gamma-glutamyltransferase were measured and the AST/ALT ratio calculated. Ideal cardiovascular health was defined as meeting ideal levels of the following components: four behaviors (smoking, body mass index, physical activity, and diet) and three factors (total cholesterol, blood pressure, and glucose). A higher number of ideal cardiovascular health behaviors, factors, and ideal cardiovascular health index were associated with lower ALT (P < 0.05, P < 0.001, and P < 0.001, respectively) and gamma-glutamyltransferase (P < 0.001, P < 0.01, and P < 0.001, respectively) levels. Similarly, a higher number of ideal cardiovascular health behaviors (P < 0.01), factors (P < 0.01), and ideal cardiovascular health index (P < 0.001) were associated with a higher aspartate aminotransferase to alanine aminotransferase ratio. These findings reinforce the usefulness of the ICH index as an instrument to identify target individuals and promote cardiovascular health in adolescents, and it also extends these observations to the liver manifestation of the metabolic syndrome.

Cardiovascular health in adults with type 1 diabetes

Adults with type 1 diabetes (T1D) are at risk for cardiovascular (CV) disease. Managing CV risk is an important prevention strategy. The American Heart Association has defined 7 factors for ideal CV health. The purpose of this 2016 secondary analysis was to assess the prevalence of 6 CV health factors in a sample of adults ≥18 (n=7153) in the T1D Exchange Clinic registry. CV health factors include: hemoglobin A1c (HbA1c) <7%, BMI<25kg/m2, blood pressure<120/80mmHg, total cholesterol <200mg/dL, non-smoking, and physical activity ≥150min/week. HbA1c<7% was substituted for the AHA health factor of fasting blood glucose. Frequencies of each factor were tabulated for the total sample and for each gender. Logistic regression examined variables associated with achievement of each CV health factor. The mean age was 37.14±17years. Mean HbA1c was 7.9±1.5%, and duration was 19.5±13.5years. The majority (54%) were working full or part-time. Achievement of CV health factors in the whole sample ranged from 27% (HbA1c<7%) to 94% nonsmoking. Achievement of some factors varied by gender. Common variables associated with several CV health factors included gender, education, employment, and T1D duration. This young sample exhibited low levels of some CV health factors, especially HbA1c and physical activity. Providers need to routinely assess and advise on management of all CV risk factors to prevent this common diabetes complication.

Social Determinants of Health Are Associated with Modifiable Risk Factors for Cardiovascular Disease and Vascular Function in Pediatric Type 1 Diabetes

OBJECTIVE

To evaluate the relationship between social determinants of health (SDH) and cardiovascular disease (CVD) risk factors as well as a measure of arterial stiffness in adolescents with type 1 diabetes (T1D).

STUDY DESIGN

SDH were measured with the validated Ontario Marginalization Index, derived from deidentified postal code data and stratified by quintile (first  = least deprived; fifth = most deprived). SDH dimensions included material deprivation; ethnic concentration; and measures of dependency and residential instability. Metabolic control (hemoglobin A1c), cardiovascular risk metrics, and pulse wave velocity, as a measure of arterial stiffness, were related to SDH. Data were evaluated from a cohort of Canadian adolescents within the Adolescent Diabetes Cardiorenal Intervention Trial, a T1D clinical trial

RESULTS

A total of 704 participants were evaluated, and significant differences in hemoglobin A1c were evident at the extremes of material deprivation (8.4% vs 9.1% for least vs most deprived, P < .01). CVD risk factors were analyzed in 199 participants, with the most deprived reporting significantly less exercise (P = .004) and increased rates of smoking (P = .008). Increased material deprivation was associated with fewer metrics of "ideal" cardiovascular health attained. Arterial stiffness, as measured by pulse wave velocity, was associated positively with age, body mass index z score, and material deprivation.

CONCLUSION

Increased material deprivation was associated with poorer glycemic control. Modifiable, lifestyle-related risk factors for CVD and early arterial wall change are associated with SDH and represent a target for clinical intervention to reduce future CVD burden in adolescents with T1D.

Cardiovascular medication use and cardiovascular disease in children and adolescents with type 1 diabetes: a population-based cohort study

OBJECTIVES

To investigate the 5-yr prevalence and incidence rates of cardiovascular medication and cardiovascular disease before and after onset of type 1 diabetes (T1D) in children and adolescents.

METHODS

Children and adolescents (<19 yr) with T1D (n = 925), defined as those who received at least two insulin prescriptions, and a four times larger reference cohort (n = 3591) with the same age and gender in the Dutch PHARMO Record Linkage System (RLS) were studied in a retrospective cohort study between 1999 and 2009. The date of first insulin dispensing was selected as the index date.

RESULTS

The overall prevalence rate of cardiovascular medication use was substantially higher in the T1D cohort before (2.2 vs. 1.0%, p < 0.001) and after (9.2 vs. 3.2%, p < 0.001) the index date. After the index date angiotensin-converting enzyme inhibitors (2.0%) and statins (1.5%) were the most prevalent cardiovascular medications in the T1D cohort. The highest incidence rate of cardiovascular medication use was observed in the first year after the index date [28.1 per 1000 person years (PY)]. Furthermore, three type 1 diabetic patients were hospitalized due to cardiomyopathy (n = 2) and heart failure (n = 1) and one child from the reference group was hospitalized due to cardiomyopathy in the 5 yr after the index date.

CONCLUSIONS

Children with T1D were more likely to use cardiovascular medications in the years before and after the onset of diabetes. Our study emphasizes the importance of routine screening tests and timely treatment of CVD risk factors in the pediatric population with diabetes.

Ideal Cardiovascular Health and Subclinical Markers of Carotid Structure and Function: The Paris Prospective Study III

OBJECTIVE

We hypothesized that subclinical markers of vascular structure and function, which are independent predictors of cardiovascular disease, would be less frequent in subjects with ideal than poor cardiovascular health (CVH) as defined by the American Heart Association (AHA).

APPROACH AND RESULTS

Carotid parameters were measured using high-precision echotracking device in 9155 nonreferred participants attending a health checkup in a large health center in Paris (France) between 2008 and 2012. According to the AHA, participants with 0 to 2, 3 to 4, and 5 to 7 metrics (smoking, physical activity, body mass index, diet, blood glucose and total cholesterol, blood pressure) at the ideal level were categorized as having poor, intermediate, and ideal CVH. Carotid parameters were dichotomized according to their median value, and multivariable logistic regression analysis was performed. Mean age was 59.5 (SD 6.3) years; 39% were females, and ideal CVH was present in 10.11% of the study participants. After adjustment for age, sex, education, and living alone and compared with a poor CVH, an ideal CVH was associated with lower common carotid artery intima-media thickness (odds ratio=1.64; 95% confidence interval 1.40, 1.93), absence of carotid plaques (odds ratio=2.14; 95% confidence interval 1.60, 2.87), lower Young's elastic modulus (odds ratio=2.43; 95% confidence interval 2.07, 2.84), and higher carotid distensibility coefficient (odds ratio=2.90; 95% confidence interval 2.47, 3.41).

CONCLUSIONS

In community subjects aged 50 to 75 years, ideal CVH was associated with substantially less arterial stiffness and thickness. These associations might contribute to the lower risk of cardiovascular diseases in subjects with ideal CVH.

Abnormalities of vascular structure and function in pediatric hypertension

Hypertension is associated with adverse cardiovascular (CV) events in adults. Measures of vascular structure and function, including increased carotid intima-media thickness (cIMT) and elevated arterial stiffness predict hard CV events in adulthood. Newer data suggest that abnormalities in target organ damage are occurring in adolescents and young adults with high blood pressure. In this review, we discuss the techniques for measuring vascular dysfunction in young people and the evidence linking blood pressure levels to this type of target organ damage.

Lipoprotein subfraction cholesterol distribution is more atherogenic in insulin resistant adolescents with type 1 diabetes

AIMS/HYPOTHESIS

Adolescents with type 1 diabetes (T1D) often have a less atherogenic-appearing fasting lipid profile than controls, despite increased rates of cardiovascular disease (CVD) as adults. We previously reported an atherogenic lipoprotein subfraction cholesterol distribution associated with insulin resistance (IR) in T1D adults. We sought to determine if T1D youth have more atherogenic profile than controls via a cross-sectional study.

METHODS

Following 3 days of controlled diet and restricted exercise, fasting plasma samples were drawn from 28 T1D youth [50% female, age 15.3 ± 2 yr, body mass index (BMI) 48%ile; diabetes duration 73 ± 52 months, hemoglobin A1c (HbA1c) 8.3 ± 1.4%] and 17 non-diabetic controls (47% female, age: 15.0 ± 2 yr, BMI 49%ile) prior to a hyperinsulinemic euglycemic clamp. Lipoproteins were fractionated by fast protein liquid chromatography (FPLC) and lipoprotein cholesterol distribution determined. Outcome measures were IR assessed by glucose infusion rate (GIR) and FPLC lipoprotein subfraction cholesterol distribution.

RESULTS

T1D youth were more IR (GIR 9.1 ± 3.6 vs. 14.7 ± 3.9 mg/kg/min, p < 0.0001) and had more cholesterol distributed as small dense low density lipoprotein-cholesterol (LDL-C) and less as large buoyant high density lipoprotein-cholesterol (HDL-C) than controls (p < 0.05), despite no differences in the fasting lipid panel. T1D girls lacked the typical female less-atherogenic profile, whereas control girls tended to have a shift toward less dense LDL-C and HDL-C vs. control boys. Among T1D, IR but not HbA1c was associated with a more atherogenic lipoprotein profile.

CONCLUSIONS/INTERPRETATIONS

Normal weight T1D youth, especially females, had more atherogenic LDL-C and HDL-C distributions which correlated with lower insulin sensitivity. IR may contribute to the increased CVD burden in T1D.

Staying Young at Heart: Cardiovascular Disease Prevention in Adolescents and Young Adults

OPINION STATEMENT

Approaches to the prevention and management of cardiovascular disease (CVD) are often too narrow in scope and initiated too late. While the majority of adolescents are free of CVD, far fewer are free of CVD risk factors, especially lifestyle factors such as poor exercise and dietary habits. Most clinicians are familiar with behavioral and pharmacologic strategies for modifying these and other traditional CVD risk factors such as hypertension, hypercholesterolemia, and diabetes. In this review, we highlight those strategies most applicable to teens and also propose fundamental reframing that recognizes the importance of early choices and life experiences to achieving cardiovascular health. Population- and individual-level approaches that support the establishment of positive health behaviors early in life are the foundation of preserving ideal cardiovascular health and promoting positive cardiovascular outcomes. The Positive Youth Development movement supports a frame shift away from seeing young people as merely the sum of their risk factors and instead as developmentally dynamic youth capable of making healthy choices. Informed by the Positive Youth Development framework, our approach to cardiovascular prevention among adolescents is both broad based and proactive, paying heed as early as possible to social, familial, and developmental factors that underlie health behaviors and employing evidence-based behavioral, pharmacologic, and surgical treatments when needed.

Association of Ideal Cardiovascular Health and Brachial-Ankle Pulse Wave Velocity: A Cross-Sectional Study in Northern China

BACKGROUND

Brachial-ankle pulse wave velocity (baPWV) is an index for evaluating arterial stiffness and is recognized as an independent predictor of an impending cardiovascular event. Limited large-scale population data are available regarding the relationship between baPWV and the change in ideal cardiovascular health (CVH) status, particularly among Asians.

METHODS

A random sample of 5199 participants (≥40 years of age; 40% women) was enrolled in a cross-sectional study in China to examine the association between ideal CVH and baPWV. Arterial stiffness was defined as a baPWV of 1400 cm/second or higher. Information on CVH was collected based on the American Heart Association's CVH definition by measuring all 7 components (nonsmoking status, body mass index, physical activity, healthy diet, normal total cholesterol, blood pressure, and fasting blood glucose), with 1 or 0 for each component, and a score from 0 to 7 for each participant.

RESULTS

A significant and inverse association was found between the ideal CVH score and baPWV (P <.001). The adjusted odds ratios for arterial stiffness prevalence were .17 (95% confidence interval [CI], .11-.26), .26 (95% CI, .19-.35), .42 (95% CI, .32-.52), .54 (95% CI, .42-.69), and .69 (95% CI, .54-.89) for those with CVH scores of 7-6, 5, 4, 3, and 2, respectively, compared with those with a CVH score of 1-0 (P <.001). Similarly graded relationships were observed in different age and gender subgroups (P <.001).

CONCLUSION

The favorable score of ideal CVH was inversely related to baPWV in Chinese adults, supporting the use of ideal CVH metrics as a useful tool for public health efforts.

Arterial stiffness in adolescents and young adults with and without type 1 diabetes: the SEARCH CVD study

BACKGROUND

Arterial stiffness is a useful parameter to predict future cardiovascular disease.

OBJECTIVE

We sought to compare arterial stiffness in adolescents and young adults with and without type 1 diabetes (T1D) and explore the risk factors associated with the differences observed.

SUBJECTS AND METHODS

Carotid-femoral pulse wave velocity (PWV), augmentation index (AI75), and brachial distensibility (BrachD) were measured in 402 adolescents and young adults with T1D (age 18.8 ± 3.3 yr, T1D duration 9.8 ± 3.8 yr) and 206 non-diabetic controls that were frequency-matched by age, sex, and race/ethnicity in a cross-sectional study. General linear models were used to explore variables associated with an increase in arterial stiffness after adjustment for demographic and metabolic covariates.

RESULTS

T1D status was associated with a higher PWV (5.9 ± 0.05 vs. 5.7 ± 0.1 m/s), AI75 (1.3 ± 0.6 vs. -1.9 ± 0.7%), and lower BrachD (6.2 ± 0.1 vs. 6.5 ± 0.1%Δ/mmHg), all p < 0.05. In multivariate models, age, sex, race, adiposity, blood pressure, lipids, and the presence of microalbuminuria were found to be independent correlates of increased arterial stiffness. After adjustment for these risk factors, T1D status was still significantly associated with arterial stiffness (p < 0.05).

CONCLUSIONS

Peripheral and central subclinical vascular changes are present in adolescents and young adults with T1D compared to controls. Increased cardiovascular risk factors alone do not explain the observed differences in arterial stiffness among cases and controls. Identifying other risk factors associated with increased arterial stiffness in youth with T1D is critical to prevent future vascular complications.

Long-term Outcomes in Youths with Diabetes Mellitus

In this article, the author reviews the long-term outcomes and their precursors of type 1 diabetes starting in youth. The author also contrasts the changing incidence of these long-term complications as we have moved from the pre-Diabetes Control and Complications Trial (DCCT) to the post-DCCT standard of care and reviews the emerging data related to complications in youths with type 2 diabetes. Finally, the author reviews the recent understanding related to the effects of diabetes on the brain and cognition.

Understanding and Improving Cardiovascular Health: An Update on the American Heart Association's Concept of Cardiovascular Health

The American Heart Association's 2020 Strategic Impact Goal is "By 2020, to improve the cardiovascular health of all Americans by 20% while reducing deaths from cardiovascular diseases and stroke by 20%." To monitor progress towards this goal, a new construct "ideal cardiovascular health" (iCVH) was defined that includes the simultaneous presence of optimal levels of seven health behaviors (physical activity, smoking, dietary intake, and body mass index) and factors (total cholesterol, blood pressure and fasting blood glucose). In this review, we present a summary of major concepts related to the concept of iCVH and an update of the literature in this area since publication of the 2020 Strategic Impact Goal, including trends in iCVH prevalence, new determinants and outcomes related to iCVH, strategies for maintaining or improving iCVH, policy implications of the iCVH model, and the remaining challenges to reaching the 2020 Strategic Impact Goal.

Magnetic resonance imaging measures of decreased aortic strain and distensibility are proportionate to insulin resistance in adolescents with type 1 diabetes mellitus

OBJECTIVES

To determine whether children with type 1 diabetes mellitus (T1DM) have evidence of increased aortic stiffness or early atherosclerosis as measured by magnetic resonance imaging (MRI).

BACKGROUND

T1DM increases risk for cardiovascular disease in adults but whether this process starts in childhood is unknown.

SUBJECTS

A total of 54 T1DM patients (15.4 ± 2.6 yr) and 30 age-matched controls (14.8 ± 2.7 yr) participated.

METHODS

MRI was performed to assess aortic arch pulse wave velocity (PWV), strain, and distensibility of the ascending and descending thoracic aorta and measures of atherosclerosis.

RESULTS

Groups were well-matched for age, pulse pressure, and gender. Low-density lipoprotein-cholesterol (LDL-C) was higher in T1DM (119.3 ± 50 vs. 76.1 ± 13.5 mg/dL, p < 0.0001). There was a trend toward decreased strain and distensibility in T1DM vs. controls in the ascending (distensibility: T1DM 62.2 ± 19.9 kPa⁻¹ × 10⁻³, control 71.6 ± 26.4 kPa⁻¹ × 10⁻³, p = 0.08) and descending aorta (strain: T1DM 25.8 ± 6.2% vs. control 28.3 ± 6.8%, p = 0.09). There was no difference in arch PWV. Advancing age and male gender was negatively associated with aortic stiffness. Hemoglobin A1c (HbA1c) was inversely related to descending aorta strain and distensibility (p < 0.05). Children with diabetes in the lowest two tertiles of insulin sensitivity demonstrated thoracic descending aortas with significantly lower strain (p = 0.027) and distensibility (p = 0.039) and increased measures of wall irregularity (p = 0.005). There were no differences in measurements of atherosclerosis between the two groups.

CONCLUSIONS

Adolescents with T1DM, especially those with lower insulin sensitivity, demonstrated a trend toward stiffer, less compliant thoracic aortas, which was inversely associated with diabetes control. These data suggest large vessel aortopathy starts early in T1DM.

Morbidity and mortality in young-onset type 2 diabetes in comparison to type 1 diabetes: where are we now?

Increasingly, we recognise that type 2 diabetes in youth is a disease with an aggressive time course and a significant complication risk. On the other hand, outcomes for youth with type 1 diabetes appear generally to be improving. With increasing numbers of both types of diabetes in youth, it is timely that a comparative perspective is offered to help clinicians prognosticate more appropriately. Contemporary comparative studies add a new perspective to a consistent story, that for youth-onset type 2 diabetes, the development and progression of cardio-renal complications are increased and the survival prognosis is significantly worse than for type 1 diabetes. Here, we review this mounting evidence, highlight the importance of metabolic syndrome factors in the excess risk and underscore that there remains a significant mortality gap for youth with either type of diabetes, to be addressed as a matter of urgency.

The SEARCH for Diabetes in Youth study: rationale, findings, and future directions

The SEARCH for Diabetes in Youth (SEARCH) study was initiated in 2000, with funding from the Centers for Disease Control and Prevention and support from the National Institute of Diabetes and Digestive and Kidney Diseases, to address major knowledge gaps in the understanding of childhood diabetes. SEARCH is being conducted at five sites across the U.S. and represents the largest, most diverse study of diabetes among U.S. youth. An active registry of youth diagnosed with diabetes at age <20 years allows the assessment of prevalence (in 2001 and 2009), annual incidence (since 2002), and trends by age, race/ethnicity, sex, and diabetes type. Prevalence increased significantly from 2001 to 2009 for both type 1 and type 2 diabetes in most age, sex, and race/ethnic groups. SEARCH has also established a longitudinal cohort to assess the natural history and risk factors for acute and chronic diabetes-related complications as well as the quality of care and quality of life of persons with diabetes from diagnosis into young adulthood. Many youth with diabetes, particularly those from low-resourced racial/ethnic minority populations, are not meeting recommended guidelines for diabetes care. Markers of micro- and macrovascular complications are evident in youth with either diabetes type, highlighting the seriousness of diabetes in this contemporary cohort. This review summarizes the study methods, describes key registry and cohort findings and their clinical and public health implications, and discusses future directions.