Diabetes care provision and glycaemic control in Northern Ireland: a UK regional audit

The impact of race and socioeconomic factors on paediatric diabetes

There are over 29,000 children and young people (CYP) with Type 1 diabetes mellitus (T1DM) in England and Wales and another 726 with Type 2 diabetes mellitus (T2DM). There is little effect of deprivation on the prevalence of T1DM whereas the association of deprivation on the percentage of CYP with T2DM is striking with 45% of cases drawn from the most deprived backgrounds. A number that has not changed over the last 4 years. Data from the UK and USA as well as other countries demonstrate the impact of deprivation on outcomes in diabetes mellitus with clear effects on measures of long-term control and complications. In the UK black CYP had higher glycosylated haemoglobin (HbA1c) values compared to other groups. Within the black group, CYP from a Caribbean background had a higher mean HbA1c (77.0 mmol/mol (9.2%)) than those from Africa (70.4 mmol/mol (8.6%)). Treatment regimen (multiple daily injections or insulin pump therapy) explained the largest proportion of the variability in HbA1c followed by deprivation. Those in the least deprived areas had an average HbA1c 5.88 mmol/mol (0.5%) lower than those living in the most deprived areas. The picture is complex as UK data also show that deprivation and ethnicity is associated with less use of technology that is likely to improve diabetes control. Increased usage of pump therapy and continuous glucose monitoring was associated with a younger age of patient (less than 10 years of age), living in the least deprived areas and white ethnicity. This gap between pump usage amongst CYP with T1DM living in the most and least deprived areas has widened with time. In 2014/15 the gap was 7.9% and by 2018/19 had increased to 13.5%. To attain an equitable service for CYP with diabetes mellitus we need to consider interventions at the patient, health care professional, community, and health care system levels.

Supplementary Nitric Oxide Donors and Exercise as Potential Means to Improve Vascular Health in People with Type 1 Diabetes: Yes to NO?

Type 1 diabetes (T1D) is associated with a greater occurrence of cardiovascular pathologies. Vascular dysfunction has been shown at the level of the endothelial layers and failure to maintain a continuous pool of circulating nitric oxide (NO) has been implicated in the progression of poor vascular health. Biochemically, NO can be produced via two distinct yet inter-related pathways that involve an upregulation in the enzymatic activity of nitric oxide synthase (NOS). These pathways can be split into an endogenous oxygen-dependent pathway i.e., the catabolism of the amino acid L-arginine to L-citrulline concurrently yielding NO in the process, and an exogenous oxygen-independent one i.e., the conversion of exogenous inorganic nitrate to nitrite and subsequently NO in a stepwise fashion. Although a body of research has explored the vascular responses to exercise and/or compounds known to stimulate NOS and subsequently NO production, there is little research applying these findings to individuals with T1D, for whom preventative strategies that alleviate or at least temper vascular pathologies are critical foci for long-term risk mitigation. This review addresses the proposed mechanisms responsible for vascular dysfunction, before exploring the potential mechanisms by which exercise, and two supplementary NO donors may provide vascular benefits in T1D.

Personal and Clinical Predictors of Poor Metabolic Control in Children with Type 1 Diabetes in Jordan

BACKGROUND

Achieving adequate metabolic control in children with type 1 diabetes is important in slowing the progression of future microvascular and macrovascular complications, but still it is a universal challenge. We aim to investigate possible factors associated with poor metabolic outcomes in Jordan as an example of a country with limited resources.

METHODS

This is a retrospective chart review study of children with type 1 diabetes. Several clinical and personal characteristics were tested for association with metabolic control reflected by HbA1c levels. Linear logistic regression analysis was used to evaluate possible predictors of metabolic control. One-way ANOVA analysis was used to detect significant differences in HbA1c between categories.

RESULTS

Significant predictors of metabolic control were found. A one-year increase in age led to an increase in HbA1c by 0.053% (P = 0.044). A decline in HbA1c levels was predicted in children who have precise amount of carbohydrates or who are receiving insulin at school (-0.46% (P = 0.014) and -0.82% (P = 0.004), respectively). When family members other than mothers decided the insulin dose, the HbA1c level increased by 0.74% (P = 0.005).

CONCLUSION

Poor metabolic control was associated with age, dietary noncompliance, not receiving insulin at school, and absence of direct mother care. Our study is one of the few studies from Middle East evaluating predictors of metabolic control. Global research studies help in giving universal insight towards developing more effective multidisciplinary team approach for diabetes care and education.

Mortality in type 1 diabetes diagnosed in childhood in Northern Ireland during 1989-2012: A population-based cohort study

OBJECTIVE

To investigate long-term mortality rates and causes of death in individuals diagnosed with type 1 diabetes before the age of 15 years during the period 1989-2012 or known to paediatric diabetes teams in 1989, in Northern Ireland.

METHODS

A cohort of 3129 patients from the Northern Ireland Childhood Diabetes Register was linked to death registrations and underlying causes, coded according to ICD-9 or ICD-10. Standardized mortality ratios (SMRs) were calculated as the ratio of observed to expected deaths by sex, attained age, time since diagnosis, calendar period, and cause of death.

RESULTS

Subjects were followed to December 31, 2012 giving 39 764 person-years of follow-up (median 12.1 years). In total, 59 subjects had died (1.5 per 1000 person-years) compared with 19.9 deaths expected, an SMR of 296 (95% confidence interval (CI) 229-382). Women had a significantly higher excess risk of mortality than men with SMRs of 535 (95% CI 361-764) and 203 (95% CI 136-291), respectively. Over half of the deaths (56%) were judged to be related or possibly related to diabetes with most of these due to acute (n = 24) or late (n = 6) complications.

CONCLUSIONS

Subjects with type 1 diabetes diagnosed less than 15 years of age had 3 times the mortality risk of the general population. Over half of the deaths were related to acute or chronic complications of diabetes.

Predictors of glucose control in children and adolescents with type 1 diabetes: results of a cross-sectional study in Cameroon

BACKGROUND

In sub-Saharan Africa the prognosis of children with type 1 diabetes is poor. Many are not diagnosed and those diagnosed have a dramatically reduced life expectancy (less than one year). The purpose of this study was to identify the predictors of glucose control in children and adolescents with type 1 diabetes.

METHODS

This hospital based cross-sectional study involved 76 children/adolescents (35 boys and 41 girls, mean age of 15.1 ± 3.1 years) with type 1 diabetes included in the "Changing Diabetes in Children" (CDiC) program and attending the clinics for children living with type 1 diabetes in the North West Region of Cameroon. Data on glycosylated haemoglobin (HbA1c) was obtained from hospital records of participants. Information on socio-demographic characteristics and diabetes related practices were obtained from participants using a structured questionnaire. Odds ratios (OR) were calculated using logistic regression models to assess the association between determinants and good glyceamic control.

RESULTS

The study population had a mean HbA1c of 10.3 ± 2.9%. Bivariate analysis indicated that having a mother as the primary caregiver (OR 0.07, 95% CI 0.02-0.2), being on 2 daily insulin injections (OR 0.2, 95% CI 0.1-0.5) and good blood glucose monitoring (BGM) adherence (OR 0.1, 95% CI 0.04-0.3) were significantly (p < 0.001) associated with better HbA1c. Minimal/moderate caregiver involvement in BGM (OR 7.7, 95% CI 2.7-22.0) and insulin injection (OR 14.9, 95% CI 4.8-46.5) were significantly (p < 0.001) associated with poor outcome. Multivariate analysis showed that having a mother as the primary caregiver (OR 0.02, 95% CI 0.002-0.189) was an independent predictor of good glucose control.

CONCLUSIONS

This study has shown that the mother's involvement in the diabetes management of their children and minimal/moderate caregiver involvement in the task of insulin injection are the most important determinants for good and poor glucose control respectively. It is currently unclear whether the direct involvement of the mother is causal or whether "mother as a primary caregiver" is just an indicator for a setting in which good diabetes treatment is possible.

Clinical, behavioural and social indicators for poor glycaemic control around the time of transfer to adult care: a longitudinal study of 126 young people with diabetes

AIMS

To describe and compare changes in glycaemic control in young people with Type 1 diabetes over time between the last 2 years in paediatric care and the first 2 years in adult care and to identify risk factors for poor glycaemic control.

METHODS

Our retrospective cohort study followed participants aged 14-22 years from 2 years before to 2 years after transfer from paediatric to adult care. Changes in glycaemic control were calculated using repeated measurements. We adjusted for gender, age at diabetes onset, age at transfer, duration of diabetes at transfer, gap (amount of time) between last paediatric and first adult visit, comorbidity, learning disability and/or mental health conditions and family structure. We examined associations between acute hospital admissions, low visit attendance rate, loss to follow-up and baseline HbA_1c level.

RESULTS

Among 126 participants, the mean HbA_1c level was 80 mmol/mol (9.4%) pre-transfer but decreased by an average of 3 mmol/mol (0.3%) each year post-transfer (P = 0.005). Young people with a learning disability and/or a mental health condition had worse glycaemic control (P = 0.041) and the mean HbA_1c of those with divorced parents was 14 mmol/mol (1.2%) higher (P = 0.014). Almost one-third of participants were admitted to the hospital for acute diabetes care. Low visit attendance rate, high baseline HbA_1c level, learning disability and/or mental health conditions and divorced parents predicted acute hospital admissions.

CONCLUSIONS

Glycaemic control improved significantly after transfer to adult care, but the mean HbA_1c level remained high. Future interventions should focus on young people with divorced parents, those with a learning disability and/or mental health condition and those who do not attend clinical visits to improve HbA_1c levels and thereby reduce hospitalization rates.

Isolated thoughts and feelings and unsolved concerns: adolescents' and parents' perspectives on living with type 1 diabetes - a qualitative study using visual storytelling

AIMS AND OBJECTIVES

To explore and describe the experiences of adolescents and their parents living with type 1 diabetes, to identify their needs for support to improve adolescents' self-management skills in the transition from child- to adulthood.

BACKGROUND

Adolescents with type 1 diabetes often experience deteriorating glycaemic control and distress. Parents are important in adolescents' ability to self-manage type 1 diabetes, but they report anxiety and frustrations. A better understanding of the challenges adolescents and parents face, in relation to the daily self-management of type 1 diabetes, is important to improve clinical practice.

DESIGN

A qualitative explorative study using visual storytelling as part of individual interviews.

METHODS

A purposive sample of nine adolescents and their parents (seven mothers, six fathers) took photographs illustrating their experiences living with type 1 diabetes. Subsequently, participants were interviewed individually guided by participants' photographs and a semistructured interview guide. Interviews were analysed using thematic analysis.

RESULTS

Four major themes were consistent across adolescents and their parents: (1) striving for safety, (2) striving for normality, (3) striving for independence and (4) worrying about future. Although adolescents and parents had same concerns and challenges living with type 1 diabetes, they were experienced differently. Their thoughts and feelings mostly remained isolated and their concerns and challenges unsolved.

CONCLUSIONS

The concerns and challenges adolescents and their parents face in the transition from child- to adulthood are still present despite new treatment modalities. Parents are fundamental in supporting the adolescents' self-management-work; however, the parties have unspoken concerns and challenges.

RELEVANCE TO CLINICAL PRACTICE

Healthcare providers should address the parties' challenges and concerns living with type 1 diabetes to diminish worries about future including fear of hypoglycaemia, the burden of type 1 diabetes and the feeling of being incompetent in diabetes self-management. It is important to focus on supporting both adolescents and their parents, and to provide a shared platform for communication.

Teenage girls with type 1 diabetes have poorer metabolic control than boys and face more complications in early adulthood

AIMS

To compare metabolic control between males and females with type 1 diabetes during adolescence and as young adults, and relate it to microvascular complications.

METHODS

Data concerning 4000 adolescents with type 1 diabetes registered in the Swedish paediatric diabetes quality registry, and above the age of 18years in the Swedish National Diabetes Registry was used.

RESULTS

When dividing HbA1c values in three groups; < 7.4% (57mmol/mol), 7.4-9.3% (57-78mmol/mol) and >9.3% (78mmol/mol), there was a higher proportion of females in the highest group during adolescence. In the group with the highest HbA1c values during adolescence and as adults, 51.7% were females, expected value 46.2%; in the group with low HbA1c values in both registries, 34.2% were females, p<0.001. As adults, more females had retinopathy, p<0.05. Females had higher mean HbA1c values at diagnosis, 11.2 vs. 10.9% (99 vs. 96mmol/mol), p<0.03, during adolescence, 8.5 vs. 8.2% (69 vs. 66mmol/mol) p<0.01, but not as young adults.

CONCLUSIONS

Worse glycaemic control was found in adolescent females, and they had a higher frequency of microvascular complications. Improved paediatric diabetes care is of great importance for increasing the likelihood of lower mortality and morbidity later in life.

Glycemic Control, Self-Efficacy and Fear of Hypoglycemia Among Iranian Children with Type 1 Diabetes

OBJECTIVE

This study was designed to test the reliability of a Persian version of 2 questionnaires to assess the level of fear of hypoglycemia (FoH) and self-efficacy in diabetes management and their association with glycated hemoglobin (A1C) and parents' demographic characteristics in a sample of children with type 1 diabetes.

DESIGN

We assessed 61 children with type 1 diabetes (35 boys and girls, 6.0 to 12.7 years of age) using the Hypoglycemia Fear Survey-Child version (HFS-C) and Self-Efficacy for Diabetes Scale-Child version (SED-C). Their glycemic control was evaluated by A1C levels.

RESULTS

The internal consistency of the Persian version of HFS-C and SED-C were very good. Our results showed that children older than 10 years of age report lower levels of FoH, which are related to higher levels of self-efficacy (r=-.30, p=0.025 and r=-.30, p=0.02, respectively). Of the children, 42.3% of girls and 31.4% of boys reported that low blood sugar is a big problem for them. These findings suggest that FoH is a significant concern for this target group. Only 19.7% of children had controlled diabetes based on A1C levels. There was no significant association between higher A1C levels and other variables, including HFS-C, SED-C and parents' demographic characteristics.

CONCLUSIONS

The Persian version of HFS-C and SED-C are reliable and valid measures of the fear of hypoglycemia and of self-efficacy in children with type 1 diabetes, and these questionnaires could be used in our country for identifying those children who may need diabetes education and other supports. The association between greater self-efficacy and lower fear of hypoglycemia suggests that addressing self-efficacy in diabetes education courses may be effective in helping to overcome FoH.

Improved metabolic control in children and adolescents with type 1 diabetes: a trend analysis using prospective multicenter data from Germany and Austria

OBJECTIVE

To investigate the temporal trend of metabolic control and potential predictors in German and Austrian children and adolescents with type 1 diabetes.

RESEARCH DESIGN AND METHODS

This study is based on a large, multicenter database for prospective longitudinal documentation of diabetes care in Germany and Austria. Data from 30,708 patients documented in 305 diabetes centers between 1995 and 2009 were analyzed. Generalized linear mixed regression models were used to adjust trend analysis for relevant confounders.

RESULTS

Unadjusted mean HbA(1c) decreased from 8.7 ± 1.8% in 1995 to 8.1 ± 1.5% in 2009. In multiple regression analysis, treatment year, age, sex, diabetes duration, migration background, BMI-SDS, and daily insulin dose were significant predictors of metabolic control (P < 0.001). After multiple adjustment, mean HbA(1c) decreased significantly by 0.038% per year (95% CI 0.032-0.043%), average odds ratio (OR) per year for HbA(1c) >7.5% (>9.0%) was 0.969 (95% CI 0.961-0.977) (0.948, 95% CI 0.941-0.956). Intensified insulin regimen was associated with lower frequency of poor metabolic control (HbA(1c) >9%; P = 0.005) but not with average HbA(1c) (P = 0.797). Rate of severe hypoglycemia and hypoglycemic coma decreased significantly (relative risk [RR] per year 0.948, 95% CI 0.918-0.979; RR 0.917, 95% CI 0.885-0.950) over the study period. Diabetic ketoacidosis rate showed no significant variation over time.

CONCLUSIONS

This study showed a significant improvement in metabolic control in children and adolescents with type 1 diabetes during the past decade and a simultaneous decrease in hypoglycemic events. The improvement was not completely explained by changes in the mode of insulin treatment. Other factors such as improved patient education may have accounted for the observed trend.

Glycemic control in children with type 1 diabetes in wales: influence of the pediatric diabetes specialist nurse

OBJECTIVE

To determine whether glycemic control is improving in diabetic children in Wales and to identify factors associated with improvement.

RESEARCH DESIGN AND METHODS

Data were collected in 2001 and 2006.

RESULTS

Over time A1C was reduced from 9.08 +/- 1.66 to 8.88 +/- 1.63% (P = 0.012). There were differences among centers (P < 0.001) and differential changes over time (interaction P < 0.001). Since 2001 five centers had appointed a pediatric diabetes specialist nurse (PDSN). A1C improved in these centers from 9.59 +/- 1.88 to 8.72 +/- 1.61% (P < 0.001). Glycemic control was worse in children aged >10 years compared with younger patients (P < 0.001). Improvement occurred in those aged >10 years. Age (P = 0.003) and insulin dose (P < 0.001) were positively and independently associated with A1C. Thus, any influence of PDSNs was not achieved through increased insulin prescription.

CONCLUSIONS

Improvement in glycemic control has occurred. Worse control is associated with greater prescribed insulin dose in older children. Appointment of PDSNs was associated with improved glycemic control among adolescents.

The geoepidemiology of type 1 diabetes

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

The Irish DAFNE study protocol: a cluster randomised trial of group versus individual follow-up after structured education for type 1 diabetes

BACKGROUND

Structured education programmes for individuals with Type 1 diabetes have become a recognised means of delivering the knowledge and skills necessary for optimal self-management of the condition. The Dose Adjustment for Normal Eating (DAFNE) programme has been shown to improve biomedical (HbA(1c) and rates of severe hypoglycaemia) and psychosocial outcomes for up to 12 months following course delivery. The optimal way to support DAFNE graduates and maintain the benefits of the programme has not been established. We aimed to compare 2 different methods of follow-up of DAFNE graduates in a pragmatic clinical trial delivered in busy diabetes clinics on the island of Ireland.

METHODS

Six participating centres were cluster randomised to deliver either group follow-up or a return to traditional one-to-one clinic visits. In the intervention arm group follow-up was delivered at 6 and 12 months post DAFNE training according to a curriculum developed for the study. In the control arm patients were seen individually in diabetes clinics as part of routine care. Study outcomes included HbA(1c) levels, self-reported rates of severe hypoglycaemia, body weight and measures of diabetes wellbeing and quality of life. These were measured at 6, 12 and 18 months after recruitment. Generalisability (external validity) was maximised by recruiting study participants from existing DAFNE waiting lists in each centre, by using broad inclusion criteria (including HbA(1c) values less than 13 percent with no lower limit) and by using existing clinic staff to deliver the training and follow-up. Internal validity and treatment fidelity were maximised by quality assuring the training of all DAFNE educators, by external peer review of the group follow-up sessions and by striving for full attendance at follow-up visits. Assays of HbA(1c) were undertaken in a central laboratory.

DISCUSSION

This pragmatic clinical trial evaluating group follow-up after a structured education programme has been designed to have broad generalisability. The results should inform how best to manage the well educated patient with Type 1 diabetes in the real world of clinical practice

TRIAL REGISTRATION

Current Controlled Trials ISRCTN79759174.

Maximising engagement, motivation and long term change in a Structured Intensive Education Programme in Diabetes for children, young people and their families: Child and Adolescent Structured Competencies Approach to Diabetes Education (CASCADE)

Background

This trial aims to evaluate effective delivery and cost effectiveness of an innovative structured psycho-educational programme (CASCADE) for young people and their families living with diabetes. The increase in numbers of people being diagnosed with diabetes is posing a challenge for both the UK and the rest of the world. The peak age for diagnosis is between 10 and 14 years of age. There is clear evidence that improved diabetes control from diagnosis in childhood can reduce the incidence and progression of long-term complications. However, despite the development of improved insulin regimens and delivery methods, the overall metabolic control in children and adolescents has improved little in the UK in the past decade. Therefore there is a need for novel interventions and health delivery mechanisms aimed at young people and their families to help improve control and reduce complications, illness burden and costs to the NHS.

Methods/Design

The CASCADE trial is a multi-centre randomised control trial with 26 clinics randomised to control or intervention groups, with 572 children and young people involved in the study. The intervention will be delivered in 4 group sessions, over a 4 month period. A developmentally appropriate curriculum will be delivered to groups of 3 - 4 families, focusing on achievement of increasing competency in self-management of diabetes. The control group will receive standard care from their clinical team, usually consisting of regular 3-monthly clinic visits and telephone contact as required with the clinical nurse specialist and consultant. The primary outcomes of the trial will be change in HbA1c between baseline and 12 months and 24 months post recruitment. Secondary outcomes will include measures related to the economic evaluation, psychosocial outcomes, outcomes related to management of diabetes outcomes, and adherence to the intervention.

Discussion

The trial will be run by independent research and service delivery teams and supervised by a trial steering committee. A data monitoring and ethics committee has been put in place to monitor the trial and recommend stopping/continuation according to a Peto-Haybittle rule. The trial will be conducted according to the principles of MRC Good Clinical Practice (GCP) Guidelines and CTRU Phase III Trial Standard Operating procedures.

Trial Registration

Current Controlled Trials ISRCTN52537669

Glycemic control and the psychosocial benefits gained by patients with type 1 diabetes mellitus attending the diabetes camp

OBJECTIVE

The aim of this study was to evaluate the effectiveness of diabetes camp on glycemic control, knowledge, and psychosocial benefits among patients with type 1 diabetes (T1D). Glycemic control among patients with infrequent and frequent self-monitoring of blood glucose (SMBG) was also compared.

METHODS

During a 5-day camp, 60 patients were taught diabetes self-management education (DSME). After camp, patients were divided into two groups based on frequency of SMBG (<3 versus 3-4 times/day) and were followed up until 6-month post-camp. Patients' HbA1c levels and knowledge were assessed at baseline, 3- and 6-month post-camp. Patients' impressions towards camp were assessed.

RESULTS

In both SMBG groups, HbA1c levels decreased significantly at 3-month post-camp but did not sustain at 6-month monitoring. The patients with frequent SMBG had a lower mean HbA1c level. A significant improvement in knowledge was noted and sustained up to 6-month post-camp. The patients found diabetes camp of benefit and felt they could better cope with diabetes.

CONCLUSIONS

Although the effect of the diabetes camp on glycemic control was short-lived, an improvement in knowledge and a better attitude towards having diabetes were seen among participants.

PRACTICE IMPLICATIONS

The psychosocial benefits and knowledge gained by patients attending diabetes camp underline the importance of including a camp in a diabetes management plan. To improve patients' long-term glycemic control, a continuous education is required.

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

AIMS/HYPOTHESIS

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

METHODS

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

RESULTS

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

CONCLUSIONS/INTERPRETATION

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

Quality of life, psychological adjustment and metabolic control in youths with type 1 diabetes: a study with self- and parent-report questionnaires

OBJECTIVE

To evaluate self and parent reports on quality of life (QoL) and psychological adjustment of youths with type 1 diabetes, in comparison to a general paediatric population, and identify relationships between disease duration, metabolic control and psychological parameters.

RESEARCH DESIGN AND METHODS

Participants included 70 youths with type 1 diabetes and their parents. They were compared with 70 non-diabetic subjects. Data were analyzed in the whole group and in subgroups aged 6-10, 11-13 and 14-18 yr. All cases performed pediatric QoL, Child Behaviour Checklist, filled in by parents, and Youth Self-Report, filled in by youths. Data were compared with haemoglobin A1c (HbA1c) values and disease duration.

RESULTS

Self-reports showed a psychological adjustment of youths with type 1 diabetes similar to that of controls. Parent reports showed that parents of children with type 1 diabetes were more worried than those of controls (p < 0.01). Adolescents showed a worse QoL and more frequent psychological disturbances. In this group, for youth and parent reports, HbA1c levels correlated positively with psychological problems (p < 0.05) and negatively with QoL (p < 0.05). Only for parent reports, in the whole group and in subgroups aged 6-10 and 11-13 yr, disease duration correlated positively with psychological adjustment (p < 0.05).

CONCLUSIONS

Before adolescence, youths with type 1 diabetes showed only slight problems in psychological adjustment and QoL, with an association with disease duration reported by parents. In adolescence, both youths and their parents reported more emotional and behavioural problems, independent of disease duration. Better metabolic control and psychological well-being seemed directly related.

Diabetes care, glycemic control, and complications in children with type 1 diabetes from Asia and the Western Pacific Region

AIMS

The incidence of type 1 diabetes is increasing in many parts of Asia, where resources may not enable targets for glycemic control to be achieved. The aims of this study were to describe glycemic control, diabetes care, and complications in youth with type 1 diabetes from the Western Pacific Region and to identify factors associated with glycemic control and hypoglycemia.

METHODS

A cross-sectional clinic-based study on 2312 children and adolescents (aged <18 years; 45% males) from 96 pediatric diabetes centers in Australia, China, Hong Kong, Indonesia, Japan, Malaysia, Philippines, Singapore, South Korea, Taiwan, and Thailand was conducted. Clinical and management details were recorded, and finger-pricked blood samples were obtained for central glycated hemoglobin (HbA(1c)).

RESULTS

The median age of the patients was 12.5 years [interquartile range (IQR)=9.4-15.3 years]; diabetes duration, 4.4 years (IQR=2.5-7.2 years); and HbA(1c) level, 8.3% (IQR 7.4%-9.7%). Insulin treatment consisted of one or two daily injections in 61% of the patients (range=22%-90% by country), and home blood glucose monitoring (range=67%-100%) was practiced by 96%. HbA(1c) level was significantly associated with country, age, diabetes duration, sex, insulin dose per kilogram, insulin regimen, and frequency of home blood glucose measurement in multiple regression analysis. The incidence of severe hypoglycemia, defined as any episode requiring assistance in the previous 3 months, was 73 per 100 patient-years and was associated with country, male sex, higher HbA(1c) level, an insulin regimen with three or more injections, and more frequent home blood glucose testing. The incidence of diabetic ketoacidosis was 10 per 100 patient-years and was associated with country, higher HbA(1c) level, and higher insulin dose per kilogram.

CONCLUSIONS

There is marked variability in glycemic control, hypoglycemia, complication rates, and diabetes care among children from the Western Pacific Region. Most are not achieving adequate glycemic control, placing them at high risk of microvascular complications.

A longitudinal observational study of insulin therapy and glycaemic control in Scottish children with Type 1 diabetes: DIABAUD 3

OBJECTIVE/BACKGROUND

Our objective was to investigate glycaemic control in children with Type 1 diabetes in Scotland and to analyse the effect of changing 'conventional' insulin regimen strategies on outcome. DIABAUD 2 (1997-1998) (D2) demonstrated that average glycaemic control in young people with Type 1 diabetes in Scotland was poor, with mean HbA(1c) of 9.0%. Over 90% were then treated with a twice-daily insulin regimen. The aim of DIABAUD 3 (2002-2004) (D3) was to determine if control had improved, and to examine changes in insulin regimen and effects on glycaemic control.

METHODS

In DIABAUD 3, data were collected prospectively on children aged < 15 years. in nine out of 15 centres throughout Scotland. HbA(1c) on 986 subjects was measured in a single Diabetes Control and Complications Trial-aligned laboratory. The results were compared with those from DIABAUD 2, for the same nine centres. Multiple regression comparison was performed to adjust for imbalance in relevant confounders (e.g. age, duration, height and weight, insulin dose and centre).

RESULTS

For D3, the age range was 1.1-14.9 years (62% aged 10-14 years), mean (+/- sd) HbA(1c) 9.2% +/- 1.5 (compared with D2, 9.0% +/- 1.5). Only 9.7% achieved the target of HbA(1c) < 7.5%. The number of subjects in D3 on twice-daily injections was 51% (compared with 94% in D2), 43% on three-times-daily injections (2% in D2) and 2.3% on four or more (1.9% in D2): HbA(1c) did not differ in these groups. In both the D2 and D3 cohorts, HbA(1c) rose with age. After adjustment for other variables in the combined datasets, insulin regimen was not a significant predictor of HbA(1c) (F = 0.19, d.f. = 3, 1774; P = 0.90).

CONCLUSION

The glycaemic control in young people in Scotland remains poor and above the national target. Over 4 years, moderate intensification of insulin therapy (i.e. from two to three injections each day, usually reflecting splitting of the evening dose) across the population failed to improve the average HbA(1c) and reduce the increase seen with age. A national programme away from 'conventional' to an 'intensive' regimen of insulin therapy is required.