Body mass index standard deviation score and obesity in children with type 1 diabetes in the Nordic countries. HbA1c and other predictors of increasing BMISDS

Prevalence, Safety, and Metabolic Control Among Danish Children and Adolescents with Type 1 Diabetes Using Open-Source Automated Insulin Delivery Systems

Background: Treatment of type 1 diabetes mellitus (T1DM) has become increasingly technical with rapid developments in integration of pumps and sensors to regulate insulin dosage, and patient-initiated solutions as open-source automated insulin delivery (OS-AID) systems, have gained popularity in people with diabetes. Studies have shown increased glycemic control and mental wellbeing in users of OS-AID systems. The aim of this study was to estimate the prevalence, the effect on metabolic control, the risk, and the effect on everyday life for users and their parents of OS-AID systems in Danish children and adolescents with T1DM. Methods: This retrospective cohort study recruited participants through pediatric diabetes outpatient clinics and social media. Surveys were distributed and current and retrospective data on glycemic control (HbA1c, time in range [TIR] etc.) were collected. Results: Fifty-six users of OS-AID systems out of 2950 Danish children and adolescents with T1DM were identified from all outpatient clinics in Denmark. Thirty-one responded on contact and were included (55% of the identified), median age 12 [interquartile range: 11-14] years, 51% females, and mean duration of use of OS-AID systems 2.37 ± 0.86 years. Glycemic control increased significantly with TIR increasing from mean 62.29% ± 13.68% to 70.12% ± 10.08%, *P < 0.01, and HbA1c decreasing from mean 50.13 ± 5.76 mmol/mol (6.7% ± 2.7%) to 47.86 ± 6.24 mmol/mol (6.5% ± 2.7%), **P < 0.05. No changes were found in safety parameters. Parents reported better quality of sleep evaluated by Pittsburgh Sleep Quality Index. Conclusion: This study is the first to provide knowledge on pediatric users of OS-AID systems in Denmark and found a prevalence of 1.89% for OS-AID systems, improved TIR, and no increased risk associated with use of OS-AID systems.

Body composition and metabolic syndrome in patients with type 1 diabetes

BACKGROUND

In recent years, the prevalence of obesity and metabolic syndrome in type 1 diabetes (T1DM) patients has gradually increased. Insulin resistance in T1DM deserves attention. It is necessary to clarify the relationship between body composition, metabolic syndrome and insulin resistance in T1DM to guide clinical treatment and intervention.

AIM

To assess body composition (BC) in T1DM patients and evaluate the relationship between BC, metabolic syndrome (MS), and insulin resistance in these indi-viduals.

METHODS

A total of 101 subjects with T1DM, aged 10 years or older, and with a disease duration of over 1 year were included. Bioelectrical impedance analysis using the Tsinghua-Tongfang BC Analyzer BCA-1B was employed to measure various BC parameters. Clinical and laboratory data were collected, and insulin resistance was calculated using the estimated glucose disposal rate (eGDR).

RESULTS

MS was diagnosed in 16/101 patients (15.84%), overweight in 16/101 patients (15.84%), obesity in 4/101 (3.96%), hypertension in 34/101 (33.66%%) and dyslipidemia in 16/101 patients (15.84%). Visceral fat index (VFI) and trunk fat mass were significantly and negatively correlated with eGDR (both P < 0.001). Female patients exhibited higher body fat percentage and visceral fat ratio compared to male patients. Binary logistic regression analysis revealed that significant factors for MS included eGDR [P = 0.017, odds ratio (OR) = 0.109], VFI (P = 0.030, OR = 3.529), and a family history of diabetes (P = 0.004, OR = 0.228). Significant factors for hypertension included eGDR (P < 0.001, OR = 0.488) and skeletal muscle mass (P = 0.003, OR = 1.111). Significant factors for dyslipidemia included trunk fat mass (P = 0.033, OR = 1.202) and eGDR (P = 0.037, OR = 0.708).

CONCLUSION

Visceral fat was found to be a superior predictor of MS compared to conventional measures such as body mass index and waist-to-hip ratio in Chinese individuals with T1DM. BC analysis, specifically identifying visceral fat (trunk fat), may play an important role in identifying the increased risk of MS in non-obese patients with T1DM.

Time-trends in body mass index, and overweight and obesity as independent risk factors for diabetes angiopathy in young females with type 1 diabetes - A nationwide study in Sweden

AIMS

To examine time-trends in BMI-distributions of young females with and without type 1 diabetes (T1D), with focus on the upper half of the distribution i.e., the median and above, and to explore if overweight and obesity independently increase risk of diabetes angiopathy.

METHODS

Population-based cohort study of 3,473 females with T1D, 16-35 years, identified in the Swedish National Diabetes Registers, January 2005 to October 2015, and 8,487 females from the background population. BMI-distributions were examined using kernel density estimates and quantile regression. Hazard ratios (HRs) and 95 % confidence intervals (CIs) for angiopathy in overweight/obese subjects were estimated with adjusted Cox regression.

RESULTS

The BMI-distribution in females with T1D was right shifted to that of the background population (p < 0.001). The 90th percentile and median BMI increased equally overtime in both groups, but females with T1D started from a higher baseline. In T1D, HRs were significantly increased for any angiopathy in individuals with obesity (adj HR 1.37 (CI 1.14-1.64)), and for retinopathy; adj HRs (CIs): overweight; 1.15 (1.02-1.29), obesity; 1.30 (1.08-1.56).

CONCLUSIONS

Females with T1D have increasing BMI overtime and are heavier than females without T1D. Overweight and obesity are by themselves risk factors for angiopathy.

Estimated glucose disposal rate is associated with retinopathy and kidney disease in young people with type 1 diabetes: a nationwide observational study

AIMS

The aim of this study was to investigate the association between estimated glucose disposal rate (eGDR), a proxy for insulin resistance, and retinopathy or kidney disease, i.e. micro-, or macroalbuminuria, in young individuals with type 1 diabetes (T1D).

MATERIAL AND METHODS

Using data from the Swedish pediatric registry for diabetes (SweDiabKids) and the registry for adults (NDR), all individuals with T1D with a duration of diabetes of less than 10 years between 1998 and 2017 were included. We calculated the crude incidence rates with 95% confidence intervals (CIs) and used multivariable Cox regression to estimate crude and adjusted hazard ratios (HRs) for two cohorts: retinopathy cohort or kidney disease cohort, stratified by eGDR categories: < 4, 4 to 5.99, 6 to 7.99, and ≥ 8 mg/kg/min (reference).

RESULTS

A total of 22 146 (10 289 retinopathy cohort, and 11 857 kidney disease cohort with an overlapping of 9575) children and adults with T1D (median age 21 years, female 42% and diabetes duration of 6 and 7 years, respectively for the cohorts) were studied. During a median follow-up of 4.8 years (IQR 2.6-7.7) there were 5040 (24.7%), 1909 (48.1%), 504 (52.3%) and 179 (57.6%) events for retinopathy in individuals with an eGDR ≥ 8, 7.99 to 6, 5.99 to 4, and < 4 mg/kg/min, respectively. Corresponding numbers for kidney disease was 1321 (6.5%), 526 (13.3%), 255 (26.8%) and 145 (46.6%). After multiple adjustments for different covariates, individuals with an eGDR 7.99 to 6, 5.99 to 4 and < 4 mg/kg/min, had an increased risk of retinopathy compared to those with an eGDR ≥ 8 mg/kg/min (adjusted HRs, 95% CIs) 1.29 (1.20 to 1.40); 1.50 (1.31 to 1.71) and 1.74 (1.41 to 2.14). Corresponding numbers for kidney disease was (adjusted HRs, 95% CIs) 1.30 (1.11 to 1.52); 1.58 (1.25 to 1.99) and 1.33 (0.95 to 1.86), respectively.

CONCLUSIONS

eGDR, a proxy for insulin resistance, is associated with retinopathy and kidney disease in young adults with T1D. The risk of retinopathy increased with lower eGDR. The risk of kidney disease also increased with lower eGDR; however results show no association between the lowest eGDR and kidney disease. eGDR can be helpful to identify young T1D individuals at risk.

The metabolic syndrome is frequent in children and adolescents with type 1 diabetes compared to healthy controls

OBJECTIVE

There is a rise in overweight and obesity among children and adolescents with type 1 diabetes (T1D) in parallel with the rise in the metabolic syndrome (MetS) among children and adolescents. The aim of the study was to describe the prevalence and characteristics of MetS in children and adolescents with T1D compared to their healthy counterparts.

RESEARCH DESIGN AND METHODS

The study includes two Danish cohorts; (i) the Copenhagen cross sectional cohort 2016 of 277 children and adolescents with T1D that attend the pediatric outpatient clinic at a large hospital in greater Copenhagen and (ii) the CHAMPS-study DK which is a population-based cohort study of Danish children and adolescents (control cohort). Participants were categorized to have MetS if at least two of the following criteria were met: (i) systolic and/or diastolic blood pressure ≥ 90th percentile, (ii) waist circumference ≥90th percentile, and (iii) triglyceride ≥90th percentile and/or HDL ≤10th percentile.

RESULTS

The prevalence of children with Mets in the T1D cohort was higher than in the control cohort (p = 0.002). Moreover, participants with T1D had MetS at a lower level of BMI (p < 0.001) and waist circumference (p < 0.001) than participants with MetS from the control cohort (z-scores = 0.90 and 1.51). Participants with MetS were younger than the other T1D participants (median 12.8 [9.9,14.8] vs. median 14.6 [11.2,16.9] years, p = 0.006).

CONCLUSIONS

Children and adolescents with T1D have an increased risk of MetS compared to healthy controls and clinicians and caretakers should consider early prevention and health promotion strategies.

The Effectiveness of Insulin Pump Therapy Versus Multiple Daily Injections in Children With Type 1 Diabetes Mellitus in a Specialized Center in Riyadh

Objectives

Comparison of continuous subcutaneous insulin infusion (CSII) with multiple daily injections (MDI) in achieving glycemic control in youths with type 1 diabetes mellitus (T1DM).

Methods

Retrospective cohort study including 2 matched groups of youths with T1DM treated by CSII or MDI in a tertiary specialized children's hospital in Saudi Arabia. Children and adolescents aged up to 18 years, diagnosed with T1DM and using CSII or MDI, from the period 2016 to 2018. Patients on MDI were newly-diagnosed patients with T1DM who had the disease for only 1 year duration; all CSII patients had at least 1 to 2 years of T1DM but who had just started on pumps in the past 3 months. We excluded patients with other autoimmune diseases, non-ambulatory patients and those admitted to hospital for non-diabetes reasons. Primary outcome was HbA1c at 1, 2, and 3 years, with weight gain as a secondary outcome. Ambulatory glycemic profile was analyzed from a subset of patients using intermittently scanned continuous glucose monitoring (isCGM).

Results

A total of 168 youths with T1DM (n = 129 in the MDI group, n = 39 in the CSII group) were included. The CSII group consistently had lower HbA1c levels compared to the MDI group throughout a 3-year follow up period: 8.1% versus 10.1, P-value < .001 at 1 year, 7.5% versus 10.1% at 2 years, P-value  < .001, 8.9% versus 10.3% at 3 years, P-value = .033. Body mass index significantly increased in both groups at 1 year, although greater in CSII group. In a subgroup using isCGM (n = 37 on MDI and n = 29 on CSII), the CSII group had a lower average blood glucose (194 mg/dL vs 228 mg/dL, P-value = .028) and a lower estimated HbA1c level (8.4% vs 9.6%, P-value = .022).

Conclusion

Treatment with CSII resulted in lower HbA1c compared to MDI in our cohort, which was sustained over a 3-year period.

Good glycemic control without exceeding the BMI trajectory during the first 5 years of treatment in children and adolescents with type 1 diabetes

OBJECTIVE

To study BMI changes and glycemic control in children and adolescents during the first 5 years following diagnosis of type 1 diabetes.

RESEARCH DESIGN AND METHODS

The 295 children and adolescents (<18 years) diagnosed with type 1 diabetes started on multiple injection treatment and were followed during the first 5 years of treatment with respect to glycemic control and weight change. Growth curves preceding the onset of diabetes were obtained from the school health services and child care centers. BMI was recalculated into BMI SD scores (BMISDS).

RESULTS

Prior to the onset of diabetes, the BMISDS was 0.46 ± 1.24 (mean ± SD), which decreased to -0.61 ± 1.36 (p < 0.001) at presentation. At 1 year, BMISDS was 0.59 ± 0.99 (p > 0.05) and increased to 0.80 ± 1.03 at 5 years; 0.97 ± 0.93 in females versus 0.68 ± 1.08 in males (p < 0.001). BMISDS at 1 year and 5 years were directly proportional to and highly predicted by BMISDS prior to the onset of type 1 diabetes, (r = 0.76; p < 0.001) vs. (r = 0.58; p < 0.001). HbA1c at 1 year was 50 ± 10 mmol/mol, which increased to 58 ± 12 mmol/mol (p < 0.001) at 5 years; females had HbA1c 60 ± 14 mmol/mol versus males 56 ± 11 mmol/mol (r = 0.35, p < 0.001). There was a correlation, irrespective of gender, between HbA1c and BMISDS at 1 year (r = 0.18, p < 0.003), but not at 5 years (r = 0.036, (p > 0.5).

CONCLUSION

During the first 5 years of treatment of type 1 diabetes in children and adolescents it is possible to achieve good glycemic control without excess weight gain.

Trends in Glycemic Control Among Youth and Young Adults With Diabetes: The SEARCH for Diabetes in Youth Study

OBJECTIVE

To describe temporal trends and correlates of glycemic control in youth and young adults (YYA) with youth-onset diabetes.

RESEARCH DESIGN AND METHODS

The study included 6,369 participants with type 1 or type 2 diabetes from the SEARCH for Diabetes in Youth study. Participant visit data were categorized into time periods of 2002-2007, 2008-2013, and 2014-2019, diabetes durations of 1-4, 5-9, and ≥10 years, and age groups of 1-9, 10-14, 15-19, 20-24, and ≥25 years. Participants contributed one randomly selected data point to each duration and age group per time period. Multivariable regression models were used to test differences in hemoglobin A1c (HbA1c) over time by diabetes type. Models were adjusted for site, age, sex, race/ethnicity, household income, health insurance status, insulin regimen, and diabetes duration, overall and stratified for each diabetes duration and age group.

RESULTS

Adjusted mean HbA1c for the 2014-2019 cohort of YYA with type 1 diabetes was 8.8 ± 0.04%. YYA with type 1 diabetes in the 10-14-, 15-19-, and 20-24-year-old age groups from the 2014-2019 cohort had worse glycemic control than the 2002-2007 cohort. Race/ethnicity, household income, and treatment regimen predicted differences in glycemic control in participants with type 1 diabetes from the 2014-2019 cohort. Adjusted mean HbA1c was 8.6 ± 0.12% for 2014-2019 YYA with type 2 diabetes. Participants aged ≥25 years with type 2 diabetes had worse glycemic control relative to the 2008-2013 cohort. Only treatment regimen was associated with differences in glycemic control in participants with type 2 diabetes.

CONCLUSIONS

Despite advances in diabetes technologies, medications, and dissemination of more aggressive glycemic targets, many current YYA are less likely to achieve desired glycemic control relative to earlier cohorts.

Overeating, binge eating, quality of life, emotional difficulties, and HbA1c in adolescents with type 1 diabetes: A Danish national survey

AIMS

To determine 1) the prevalence of symptoms of overeating (OE), subclinical binge eating (SBE) and clinical binge eating (CBE), in adolescents with type 1 diabetes (T1D), and 2) their associations with quality of life (QoL), anxiety, depression, HbA_1c, and body mass index standard deviation score (BMISDS).

METHODS

In total 506 adolescents (age 12-17 years; mean 14.7 years; girls 49%) from the Danish Registry for Diabetes in Childhood and Adolescence (DanDiabKids) were included. Participants completed questionnaires on disordered eating, QoL, and emotional difficulties. A blood sample was sent for HbA_1c determination. BMISDS was determined from the DanDiabKids data.

RESULTS

Prevalence rates of OE, SBE, and CBE were 8.4%, 18% and 7.9% respectively. Youth with CBE symptoms scored lowest on generic and diabetes specific QoL, highest on anxiety and depression symptoms, and had a higher HbA_1c. Youth with CBE had borderline increased BMISDS.

CONCLUSIONS

In a Danish national survey of adolescents with T1D, approximately one-third of participants had overeating or binge eating symptoms, comparable with the numbers in a U.S T2D population. Increased binge eating symptoms associated with lower QoL, higher depression scores, higher anxiety scores, and poorer clinical outcomes. Binge eating symptoms were markers for poor mental and somatic health.

Association of the use of diabetes technology with HbA1c and BMI-SDS in an international cohort of children and adolescents with type 1 diabetes: The SWEET project experience

OBJECTIVE

To examine the association between the use of diabetes technology (insulin pump [CSII], glucose sensor [CGM] or both) and metabolic control (HbA1c) as well as body adiposity (BMI-SDS) over-time in a cohort of children and adolescents with type 1 diabetes (T1D), that have never used these technologies before.

SUBJECTS AND METHODS

Four thousand six hundred forty three T1D patients (2-18 years, T1D ≥1 year, without celiac disease, no CSII and/or CGM before 2016) participating in the SWEET prospective multicenter diabetes registry, were enrolled. Data were collected at two points (2016; 2019). Metabolic control was assessed by glycated hemoglobin (HbA1c) and body adiposity by BMI-SDS (WHO). Patients were categorized by treatment modality (multiple daily injections [MDI] or CSII) and the use or not of CGM. Linear regression models, adjusted for age, gender, duration of diabetes and region, were applied to assess differences in HbA1c and BMI-SDS among patient groups.

RESULTS

The proportion of patients using MDI with CGM and CSII with CGM significantly increased from 2016 to 2019 (7.2%-25.7%, 7.8%-27.8% respectively; p < 0.001). Linear regression models showed a significantly lower HbA1c in groups that switched from MDI to CSII with or without CGM (p < 0.001), but a higher BMI-SDS (from MDI without CGM to CSII with CGM p < 0.05; from MDI without CGM to CSII without CGM p < 0.01).

CONCLUSIONS

Switching from MDI to CSII is significantly associated with improvement in glycemic control but increased BMI-SDS over-time. Diabetes technology may improve glucose control in youths with T1D although further strategies to prevent excess fat accumulation are needed.

Comparing continuous subcutaneous insulin infusion and multiple daily injections in children with Type 1 diabetes in Sweden from 2011 to 2016-A longitudinal study from the Swedish National Quality Register (SWEDIABKIDS)

OBJECTIVE

This study aimed to compare metabolic control measured as hemoglobin A1c (HbA1c), the risk of severe hypoglycemia, and body composition measured as body mass index standard deviation scores (BMI-SDS) in a nationwide sample of children and adolescents with Type 1 diabetes with continuous subcutaneous insulin infusion (CSII) and multiple daily injections (MDI), respectively.

RESEARCH DESIGN AND METHODS

Longitudinal data from 2011 to 2016 were extracted from the Swedish National Quality Register (SWEDIABKIDS) with both cross-sectional (6 years) and longitudinal (4 years) comparisons. Main end points were changes in HbA1c, BMI-SDS, and incidence of severe hypoglycemia.

RESULTS

Data were available from 35,624 patient-years (54% boys). In general, HbA1c decreased approximately 0.5% (2-5 mmol/mol) from 2011 to 2016 (p_trend  < 0.001) and the use of CSII increased in both sexes and all age groups. Mean HbA1c was 0.1% (0.7-1.5 mmol/mol) lower in the CSII treated group. Teenagers, especially girls, using CSII tended to have higher BMI-SDS. There was no difference in the number of hypoglycemias between CSII and MDI over the years 2011-2016.

CONCLUSIONS

There was a small decrease in HbA1c with CSII treatment but of little clinical relevance. Overall, mean HbA1c decreased in both sexes and all age groups without increasing the episodes of severe hypoglycemia, indicating that other factors than insulin method contributed to a better metabolic control.

Trajectories in glycated hemoglobin and body mass index in children and adolescents with diabetes using the common data model

We evaluated trajectories of glycated hemoglobin (HbA1c) levels and body mass index z-scores (BMIz) for 5 years after diagnosis among Korean children and adolescents with type 1 diabetes (T1D) or type 2 diabetes (T2D) using the common data model. From the de-identified database of three hospitals, 889 patients < 15 years of age diagnosed with T1D or T2D (393 boys, 664 T1D patients) were enrolled. Diagnosis was defined as first exposure to antidiabetic drug at each center. Compared with T2D patients, T1D patients had lower BMIz at diagnosis (- 0.4 ± 1.2 vs. 1.5 ± 1.4, p < 0.001) and 3 months (- 0.1 ± 1.0 vs. 1.5 ± 1.5, p < 0.001), and higher HbA1c levels at diagnosis (10.0 ± 2.6% vs. 9.5 ± 2.7%, p < 0.01). After 3 months, HbA1c levels reached a nadir of 7.6% and 6.5% in T1D and T2D patients, respectively, followed by progressive increases; only 10.4% of T1D and 29.7% of T2D patients achieved the recommended HbA1c target (< 7.0%) at 60 months. T1D patients showed consistent increases in BMIz; T2D patients showed no significant change in BMIz during follow-up. Peri-pubertal girls with T1D had higher HbA1c and BMIz values. Achieving optimal glycemic control and preventing obesity should be emphasized in pediatric diabetes care.

Association between glycaemic outcome and BMI in Danish children with type 1 diabetes in 2000-2018: a nationwide population-based study

AIM

To describe the development of HbA_1c and BMI over time in Danish children with type 1 diabetes; and to investigate the association between HbA_1c and BMI including influence of age, gender, diabetes duration, severe hypoglycaemia and treatment method.

METHODS

We used the nationwide Danish Registry of Childhood and Adolescent Diabetes, DanDiabKids, including annual registrations of all children with diabetes treated at Danish hospitals. With linear mixed-effects models and splines we analyzed the HbA_1c and BMI development over time as well as the association between HbA_1c and BMI including effects of gender, age, disease duration, hypoglycaemia and treatment method. BMI z-scores were calculated for these analyses.

RESULTS

For the period from 2000 to 2018, 6097 children with type 1 diabetes were identified from the DanDiabKids database. The median (interquartile range) HbA_1c level was 65 (57-74) mmol/mol (8.1%) and the median BMI z-score was 0.85 in girls and 0.67 in boys. A non-linear association was found between HbA_1c and BMI z-score, with the highest BMI z-score observed for HbA_1c values in the range of approximately 60-70 mmol/mol (7.6-6.8%). The association was modified by gender, age and diabetes duration. Severe hypoglycaemia and insulin pump treatment had a small positive impact on BMI z-score.

CONCLUSION

The association between HbA_1c and BMI z-score was non-linear, with the highest BMI z-score being observed for intermediate HbA_1c levels; however, specific patterns depended on gender, age and diabetes duration.

Treatment and long-term follow-up of patients diagnosed with type 1 diabetes mellitus before age 5

OBJECTIVES

This study aimed to determine the effects of continuous subcutaneous insulin infusion (CSII) treatment on anthropometric measurements, mean HbA1c, and insulin dosage in patients diagnosed under 5 years of age and compare with multiple-dose injection therapy (MDI).

METHODS

Children with type 1 diabetes mellitus, diagnosed <5 years since 2000 and their 19-year follow-up were evaluated retrospectively. Weight, height, body mass index (BMI), blood pressure, and HbA1c values were recorded for each visit.

RESULTS

Hundred and five patients (58.1% female, 41.9% male) were included in the study. Sixty-three (60 %) patients were treated by CSII and 42 (40%) by MDI. Mean age at diagnosis was 2.68 ± 1.42 and 3.29 ± 1.30 years respectively. Mean follow-up was 7.42 ± 4.76 and 6.01 ± 4.41 years respectively. For each group, weight standard deviation score (SDS) increased significantly in the first year after the diagnosis (p<0.001), and with the onset of puberty weight SDS decreased significantly (p<0.001). The trend of weight and BMI SDS changes over the years showed similar characteristics in both groups. During follow-up height SDS was similar in both groups except in Tanner stage 5. When puberty was completed, mean height SDS was 0.51 ± 1.03 in CSII and -0.31 ± 0.75 in the MDI group (p: 0.029). Mean HbA1c was significantly lower in the CSII group (7.62 ± 0.82 and 8.17 ± 1.22 respectively). Systolic and diastolic blood pressure change trends during the follow-up were also similar in both groups.

CONCLUSIONS

CSII treatment had positive effects on metabolic control and height SDS in patients with early-onset diabetes without increasing BMI.

The durability and effectiveness of sensor-augmented insulin pump therapy in pediatric and young adult patients with type 1 diabetes

PURPOSE

Despite the prevalent use of insulin pump therapy worldwide, few studies have been conducted among young patients with type 1 diabetes (T1D) in Korea. We investigated the durability and effectiveness of insulin pump therapy among Korean pediatric and young adult patients with T1D.

METHODS

This study included 54 patients with T1D diagnosed at pediatric ages (range, 1.1-14.1 years) who initiated insulin pump therapy during 2016-2019 at Seoul National University Children's Hospital and Seoul National University Bundang Hospital. Clinical and biochemical data, including anthropometric measurements, insulin dose, and glycated hemoglobin (HbA1c) levels were obtained from T1D diagnosis to last follow-up.

RESULTS

Forty-four patients (81.5%) continued insulin pump therapy with a median pump use duration of 2.9 years (range, 0.2-3.5 years); 10 discontinued the therapy within 12 months (<1 month, n=6; 1-6 months, n=1; and 6-12 months, n=3) due to physical interferences or financial problems. Older age (≥10 years of age) and longer diabetes duration (≥2 years) at the initiation of pump therapy were associated with discontinuation (P<0.05 for both). For patients continuing pump therapy, HbA1c levels significantly decreased after 1 year of therapy (from 8.9% to 8.1%, P<0.001) without changes in the body mass index z-scores or insulin dose. Although 4 patients experienced diabetic ketoacidosis, all recovered without complications.

CONCLUSION

Insulin pump therapy was effective in improving glycemic control in T1D patients during 12 months of treatment. Early initiation of insulin pump therapy after T1D diagnosis was helpful for continuing therapy.

Influence of Socio-Economic and Cultural Factors on Type 1 Diabetes Management: Report from a Tertiary Care Multidisciplinary Diabetes Management Center in India

OBJECTIVE

To study the association of socio-economic (SE) and cultural factors with HbA1c and diabetes knowledge of children, adolescents and young adults with T1DM managed in the authors' centre, as these may be unique to a country or a region.

METHODS

Demographic details, SE scoring, body mass index and mean of the last two HbA1c values were recorded, in 173 eligible patients. A diabetes knowledge test (DKT) was administered.

RESULTS

Median (range) age was 14.0 (3.25-25.5) y and HbA1c 8.2 ± 1.3%. The patients travelled a median of 124 (range 0.5-850) km and 2.3 (range 0.1-18.3) h each way, to reach the clinic. Only 2 children took insulin at school / college. Insulin adjustment for pre-meal blood glucose was practiced by 88%, but adjustment for meal intake by only 17% patients. Median HbA1c was lower in the participants with age > 18 y [7.7 (5.6-11.0) %] vs. < 10 y [8.3 (6.3-10.6) %, p < 0.02] or 10-18 y [(8.3 (5.9-12.6) %, p < 0.02)]. Overweight /obesity were seen in 35%. On multivariate regression, HbA1c was associated negatively with DKT score (DKTS) and age group, and DKTS was associated positively with urban residence and maternal education > class 12th. HbA1c and DKTS were not associated with income.

CONCLUSIONS

Low income may be successfully compensated by other factors to obtain good glycemic control. HbA1c did not deteriorate in adolescence in contrast to world experience. Overweight is a worrisome problem. Improved societal awareness about childhood diabetes is crucial.

Decreased markers of bone turnover in children and adolescents with type 1 diabetes

BACKGROUND AND AIM

Adults with type 1 diabetes (T1D) have increased risk of bone fractures and decreased bone mineral density (BMD). Alterations in bone turnover have been suggested as the link between T1D and the impaired bone health. Furthermore, bone turnover has been suggested to have beneficial effects on glucose metabolism. This study aimed at describing bone turnover markers (BTM), and the relationship with glycemic control, in children and adolescents with T1D.

METHODS

A total of 173 (47% girls) children and adolescents aged 7.7 to 17.5 years with T1D for more than 1 year were included. Participants were evaluated by BMD together with measurements of selected BTM; two formation markers: osteocalcin (OCN) and procollagen type-1 amino-terminal propeptide (P1NP) and one resorption marker, C-terminal cross-linked telopeptide of type-1 collagen (CTX). BTM were converted into Z-scores utilizing new national references.

RESULTS

Mean OCN Z-score (-0.68 ± 1.31), P1NP Z-score (-0.33 ± 1.03) and CTX Z-score (-0.43 ± 1.10) were all significantly lower than the reference population (P < .001). No associations were seen between BTM and T1D duration. BMD Z-score was comparable to the reference population and associated with none of individual BTMs. CTX Z-score was negatively associated with HbA1c (P = .007) independent of both exogenous and residual endogenous insulin.

CONCLUSIONS

Markers of bone formation and resorption were decreased in children and adolescents with T1D. CTX Z-score associated negatively with HbA1c adjusted for insulin treatment and endogenous insulin production indicating a potential association between CTX and insulin sensitivity. The long-term consequences of decreased BTM on BMD need further attention.

Geographical variation in the incidence of type 1 diabetes in the Nordic countries: A study within NordicDiabKids

BACKGROUND

The incidence of type 1 diabetes (T1D) is high in the Nordic countries with geographic differences between as well as within countries.

OBJECTIVE

To describe the geographical distribution of the incidence of T1D among children in four Nordic countries, an area where the population is considered genetically similar.

METHODS

Data on children 0 to 14 years of age and diagnosed with T1D 2006 to 2011 was collected from four Nordic national pediatric quality diabetes registries. Data included year of diagnosis (2006-2011), sex, and age at diagnosis. Figures for number of children at risk during 2006 to 2011-as well as total population, proportion with foreign background and size of populated areas of geographic regions-were collected from official statistics.

RESULTS

The total incidence during the study period for all four countries was 35.7/100 000 person years but differed between the countries (range 18.2-44.1; P < .001). The incidence difference between the countries was most obvious in the highest age group, 10 to 14 years of age, whereas there was no difference in the youngest age group 0 to 5 years of age. Iceland had similar incidence in the entire country, whereas the other countries had areas with different incidence. Densely populated areas, such as major cities, had the lowest incidence.

CONCLUSION

The incidence of T1D differed between the Nordic countries and also between the neighboring countries and generally decreased with population density. This indicates that environmental factors may contribute to the level of incidence of T1D.

Type 1 diabetes and body composition in youth: A systematic review

An increasing prevalence of overweight and obesity was reported in youth with type 1 diabetes, likely due to the intensive insulin treatment and/or an unhealthy lifestyle. Analyses of body composition may help describe the real increase in fat mass, which contributes to the diabetes-related cardio-metabolic risk. This systematic review evaluated the current literature on body composition assessments in youth with type 1 diabetes and the potential association with cardio-metabolic, functional, or behavioural risk factors. A systematic search of literature studies reporting assessments of body composition in youth with type 1 diabetes published until April 2018 was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Twenty-three articles with different study designs reported assessments of body composition. The following methods were used to assess body composition: computerized dual energy X-ray absorptiometry (n = 10), bioelectrical impedance analysis (n = 8), skinfold thickness measurement (n = 4), and air displacement plethysmography (n = 1). Higher fat mass values were found in youth with type 1 diabetes in seven of the 13 studies that included a healthy control group. Most studies investigating the association between body composition and cardio-metabolic risk factors showed that youth with higher fat mass levels had poor glycaemic control, dyslipidaemia, or higher blood pressure. Assessments of body composition may represent a useful clinical procedure to support decision-making in type 1 diabetes management. Further research is needed to standardize the assessment of body composition and develop a consensus guideline.

Proportion of Basal to Total Insulin Dose Is Associated with Metabolic Control, Body Mass Index, and Treatment Modality in Children with Type 1 Diabetes-A Cross-Sectional Study with Data from the International SWEET Registry

OBJECTIVES

To investigate in a large population the proportion of daily basal insulin dose (BD) to daily total insulin dose (TD) (BD/TD) and its association with glycated hemoglobin A1c (HbA1c), body mass index (BMI)- SDS, and treatment modality in children with type 1 diabetes.

STUDY DESIGN

Cross-sectional study in subjects with type 1 diabetes, age ≤18 years, and ≥2 years of diabetes duration, registered in the international multicenter Better control in Pediatric and Adolescent diabeteS: Working to crEate CEnTers of Reference registry in March 2018. Variables included region, sex, age, diabetes duration, treatment modality (multiple daily injections [MDI] or continuous subcutaneous insulin infusion [CSII]), self-monitoring blood glucose, HbA1c, BD/TD, and BMI-SDS. BMI was converted to BMI-SDS using World Health Organization charts as reference. Hierarchic linear regression models were applied with adjustment for age, sex, and diabetes duration.

RESULTS

A total of 19 687 children with type 1 diabetes (49% female, 49% CSII users) with median age 14.8 (11.5; 17.2) years and diabetes duration 6.0 (3.9; 9.0) years were included. HbA1c was 63 (55; 74) mmol/mol (7.9 [7.2; 8.9]%), and BMI-SDS 0.55 (-0.13; 1.21). Unadjusted, a lower BD/TD was associated with lower HbA1c, male sex, younger age, shorter diabetes duration, lower BMI-SDS, higher numbers of self-monitoring blood glucose and CSII (all P < .01). After adjustment for confounders, lower BD/TD was associated with lower HbA1c (P < .01) and lower BMI-SDS (P < .01) in children on CSII, but not on MDI.

CONCLUSIONS

Lower BD/TD is positively associated with lower HbA1c and lower BMI-SDS in children with type 1 diabetes on CSII. It remains to be investigated in a prospective study whether reducing BD/TD insulin will improve metabolic control and normalize body weight in children with type 1 diabetes.