Diabetes in puberty

The natural history of emerging diabetic retinopathy and microalbuminuria from prepuberty to early adulthood in Type 1 diabetes: A 19-year prospective clinical follow-up study

OBJECTIVE

To evaluate the impact of long-term glycaemic control and glycaemic variability on microvascular complications in adolescents and young adults with childhood-onset Type 1 diabetes.

METHODS

Twenty-six participants took part in a prospective follow-up study. We used univariate generalised estimating equations (GEE) analysis with first-order autoregressive AR(1) covariance structure for repeated measurements to evaluate the relationship between emerging diabetic retinopathy (DR) and each single explanatory variable, namely age at developmental stages from late prepuberty until early adulthood, duration of diabetes and long-term HbA_1c . Thereafter, the simultaneous effect of these three explanatory variables to DR was analysed in a multivariate model.

RESULTS

Twenty-five participants developed DR by early adulthood after a median diabetes duration of 16.2 years (range 6.3-24.0). No participants had DR during prepuberty. Each of the three variables was independently associated with emerging DR: age (OR 1.47, 95% CI to 1.25 to 1.74, p < 0.001) stronger than diabetes duration (OR 1.42, 95% CI 1.23 to 1.63, p < 0.001) and HbA_1c (OR 1.02, 95% CI 1.001 to 1.05, p = 0.041) in this population. In the multivariate analysis of these three explanatory variables, only age was associated with DR (adjusted OR 1.52, 95% CI 1.10 to 2.10, p = 0.012).

CONCLUSIONS

The emergence of DR during adolescence and early adulthood is not rare and increases with age in patients with deteriorating metabolic control during puberty and thereafter. This underpins the need to prevent deterioration of glycaemic control from taking place during puberty-seen again in this follow-up study-in children with diabetes.

Disordered Eating Behaviors Among Italian Adolescents with Type 1 Diabetes: Exploring Relationships with Parents' Eating Disorder Symptoms, Externalizing and Internalizing Behaviors, and Body Image Problems

The purpose of this study is to examine associations of disordered eating behaviors (DEBs) with body image problems, parents' eating disorder symptoms, and emotional and behavioral problems among adolescents with type 1 diabetes (T1D). 200 adolescents (M age = 15.24 ± 1.45 years) with T1D completed a self-report measure of DEBs and body ideal internalization, and their parents completed self-report measures of parents' eating problems and child's psychological symptoms. Seventy-three (36.5%) adolescents were DEPS-r-positive (scores ≥ 20), with higher rates among girls (χ² = 9.034, p = .003). Adolescents with T1D and DEBs reported lower SES, worse metabolic control, higher zBMI (p < .001), more eating disorder symptoms, more body image problems, and more emotional and behavioral problems than adolescents with T1D but no DEBs (all p < .05). Parents of adolescents with DEBs showed higher levels of bulimia (p = .028) than parents of adolescents without DEBs. In both genders, pressure to conform to societal norms about body image (p < .01) and externalization symptoms (p < .05) emerged as significant predictors of DEBs. Findings suggest that adolescents with T1D and DEBs showed an alarming psychological condition, with higher level of body image and more emotional and behavioral problems.

Effects of noopept on cognitive functions and pubertal process in rats with diabetes

AIM

Type 1 diabetes (T1DM) is a common chronic disease in childhood. Increasing insulin resistance in puberty gives rise to higher doses of insulin usage in treatment. Of this reason new approaches in treatment are needed. Noopept researches suggest it to have anti-diabetic properties. We tried to determine the effects of noopept on pubertal diabetes.

MAIN METHOD

The research was made with 60 prepubertal, 28 day-old, male, Sprague Dawley rats. The rats were divided into randomised 6 groups (n = 10/group). i) Control, ii) Diabetes Control, iii) Noopept Control, iv) Diabetes + Noopept, v) Diabetes + Insulin, vi) Diabetes + Insulin + Noopept. T1DM model was induced by streptozotocin on postnatal 28th day. 0.5 mg/kg noopept and 1 IU insulin were administered intraperitoneally for 14 days. Blood glucose and body weight measurements, puberty follow-up and MWM tests were performed. Hippocampus, hypothalamus and testis were evaluated histologically. Hypothalamic GnRH and kisspeptin were studied immunohistochemically. Serum LH, FSH and insulin, hippocampal homogenate NGF and BDNF levels were determined by ELISA.

KEY FINDINGS

Delayed puberty was normalized by noopept (p < 0.05). Blood glucose levels were lower in noopept-administered diabetic groups (p < 0.05). Noopept decreased HOMA-IR in insulin administered diabetic group (p < 0.05). Number of degenerated cells in hippocampus and testis were higher in diabetes control group when compared with other groups (p < 0.05). GnRH immunoreactivity in Diabetes + Noopept group was increased when compared to insulin + noopept group (p = 0.018). There was no difference in kisspeptin, serum LH, FSH, hippocampal NGF-BDNF levels and spatial learning assessment among groups (p > 0.05).

SIGNIFICANCE

Noopept may have positive effect in treatment of pubertal diabetes.

The Adolescent Cardio-Renal Intervention Trial (AdDIT): retinal vascular geometry and renal function in adolescents with type 1 diabetes

AIMS/HYPOTHESIS

We examined the hypothesis that elevation in urinary albumin creatinine ratio (ACR) in adolescents with type 1 diabetes is associated with abnormal retinal vascular geometry (RVG) phenotypes.

METHODS

A cross-sectional study at baseline of the relationship between ACR within the normoalbuminuric range and RVG in 963 adolescents aged 14.4 ± 1.6 years with type 1 diabetes (median duration 6.5 years) screened for participation in AdDIT. A validated algorithm was used to categorise log10 ACR into tertiles: upper tertile ACR was defined as 'high-risk' for future albuminuria and the lower two tertiles were deemed 'low-risk'. RVG analysis, using a semi-automated computer program, determined retinal vascular calibres (standard and extended zones) and tortuosity. RVG measures were analysed continuously and categorically (in quintiles: Q1-Q5) for associations with log10 ACR and ACR risk groups.

RESULTS

Greater log10 ACR was associated with narrower vessel calibres and greater tortuosity. The high-risk group was more likely to have extended zone vessel calibres in the lowest quintile (arteriolar Q1 vs Q2-Q5: OR 1.67 [95% CI 1.17, 2.38] and venular OR 1.39 [0.98, 1.99]) and tortuosity in the highest quintile (Q5 vs Q1-Q4: arteriolar OR 2.05 [1.44, 2.92] and venular OR 2.38 [1.67, 3.40]). The effects of retinal vascular calibres and tortuosity were additive such that the participants with the narrowest and most tortuous vessels were more likely to be in the high-risk group (OR 3.32 [1.84, 5.96]). These effects were independent of duration, blood pressure, BMI and blood glucose control.

CONCLUSIONS/INTERPRETATION

Higher ACR in adolescents is associated with narrower and more tortuous retinal vessels. Therefore, RVG phenotypes may serve to identify populations at high risk of diabetes complications during adolescence and well before onset of clinical diabetes complications.

Association between Vascular Endothelial Markers and Carotid Intima-Media Thickness in Children and Adolescents with Type 1 Diabetes Mellitus

Introduction

Type 1 Diabetes Mellitus (T1DM) is one of the important risk factor for cardiovascular disease. Endothelial dysfunction and increased Carotid Intima-Media Thickness (CIMT) result in cardiovascular complications. Vascular Cell Adhesion Molecule-1 (VCAM-1) and Intercellular Adhesion Molecule-1 (ICAM-1) are two adhesion molecules that are markers of early atherosclerosis and play a significant role in developing atherosclerosis.

Aim

To evaluate CIMT and its association with the levels of ICAM-1 and VCAM-1 in children and adolescents with T1DM.

Materials and Methods

In this descriptive, cross-sectional study conducted between April 2013 and September 2014, 29 children aged 7-20 years with T1DM for at least two years and 29 age and sex-matched, healthy individuals were evaluated. Plasma level of ICAM-1 and VCAM-1 was measured by ELISA, and CIMT via Doppler ultrasound was also assessed. The data were analysed by t-test and Pearson's correlation coefficient in SPSS 16.0 (p≤0.05).

Results

Independent t-test indicated that there is a significant difference in ICAM-1 level between the patients and controls (p<0.001). Further, CIMT was significantly higher in diabetic subject (p<0.001). CIMT was not significantly associated with the level of VCAM-1 and ICAM-1 in the patients (p>0.5).

Conclusion

ICAM-1 and VCAM-1 were not associated with CIMT but, CIMT and level of ICAM-1 were significantly, higher in diabetic patients, and therefore could be used as useful tools for identification of early atherosclerosis in children and adolescents with T1DM.

Current use of metformin in addition to insulin in pediatric patients with type 1 diabetes mellitus: an analysis based on a large diabetes registry in Germany and Austria

BACKGROUND

With increasing obesity in childhood and adolescence, weight gain, and insulin resistance become also more frequent in patients with type 1 diabetes mellitus (T1DM). Especially during puberty, insulin therapy often has to be intensified and higher insulin doses are necessary. Some studies point to a beneficial effect of metformin in addition to insulin in these patients. In order to describe current practice and possible benefits, we compared pediatric T1DM patients with insulin plus metformin (n = 525) to patients with insulin therapy only (n = 57 487) in a prospective multicenter analysis.

METHODS

Auxological and treatment data from 58 012 patients aged <21 yr with T1DM in the German/Austrian Diabetes Patienten Verlaufsdokumentation (DPV) registry were analyzed by multivariable mixed regression modeling.

RESULTS

Patients with additional metformin were older [median (interquartile range)]: [16.1 (14.1-17.6) vs. 15.2 (11.5-17.5) yr] with female preponderance (61.0 vs. 47.2%, p < 0.01). They had higher body mass index-standard deviation score (BMI-SDS) [+2.03 (+1.29 to +2.56) vs. +0.51 (-0.12 to +1.15); p < 0.01] and glycated hemoglobin (HbA1c) (9.0 vs. 8.6%, p < 0.01). Hypertension (43.7 vs. 24.8%) and dyslipidemia (58.4 vs. 40.6%) were significantly more prevalent. Adjusted insulin dose was significantly higher (0.98 vs. 0.93 IU/kg bodyweight). In a subgroup of 285 patients followed-up longitudinally (average treatment period 1.42 yr), addition of metformin resulted in a slight reduction of BMI-SDS [-0.01 (-2.01 to +1.40)], but did not improve HbA1c or insulin requirement.

CONCLUSION

Additional metformin therapy in T1DM is primarily used in obese females. Additional therapy with metformin was associated with minor benefits.

Understanding adolescent type 1 diabetes self-management as an adaptive process: A grounded theory approach

OBJECTIVE

To develop a conceptual understanding of the process of adapting to the self-management of type 1 diabetes during adolescence.

DESIGN

Participants were recruited from a National Health Service paediatric diabetes service within the south-west of England which runs six countywide diabetes clinics. Thirteen interviews were conducted using a social constructivist grounded theory approach.

RESULTS

The findings illustrate how self-management can be understood in terms of a continuum-based framework, ranging from difficulties with, to successful self-management. Adaptation within the continuum can further be understood by specific transitional phases and process mechanisms, providing further depth to individuals' experiences of adaptation.

CONCLUSION

This investigation provides a conceptual understanding of the complex issues adolescents encounter while adapting to and integrating a diabetes self-management regime into their lives. It provides an invaluable framework for exploring psychological mechanisms and contextualising them within a self-management continuum. Implications for healthcare professionals are discussed and further research proposes whether the model could be applicable to other chronic illnesses.

Predictors of increasing BMI during the course of diabetes in children and adolescents with type 1 diabetes: data from the German/Austrian DPV multicentre survey

OBJECTIVE

Increased weight gain has been reported prior to disease onset (accelerator hypothesis) and as a side effect of intensified insulin therapy in type 1 diabetes (T1D). Paediatric studies are complicated by the age-dependency and gender-dependency of BMI, and also by a trend towards obesity in the general population. The aim of this study was to evaluate factors related to the increase in BMI during the course of diabetes in children and adolescents with T1D in a large multicentre survey.

DESIGN

Within the DPV database (Diabetespatienten Verlaufsdokumentation) a standardised, prospective, computer-based documentation programme, data of 53,108 patients with T1D, aged <20 years, were recorded in 248 centres. 12,774 patients (53% male, mean age 13.4±3.9, mean diabetes duration 4.7±3.0 years and mean age at diabetes onset 8.7±4.0 years) were included in this analysis. Population-based German reference data were used to calculate BMI-SDS and define overweight and obesity.

RESULTS

12.5% of T1D patients were overweight and 2.8% were obese. Multiple longitudinal regression analysis revealed that female gender, low BMI at diabetes onset, intensified insulin therapy and higher insulin dose, as well as pubertal diabetes onset, long diabetes duration and onset in earlier calendar years among girls, were related to higher BMI-SDS increase during the course of diabetes (p<0.01; all).

CONCLUSIONS

Intensified insulin regimen is associated with weight gain during T1D treatment, in addition to demographic variables. Optimisation of diabetes management, especially in females, might limit weight gain in order to reduce overweight and obesity together with comorbidities among paediatric T1D patients.

Accuracy in Discriminating Blood Glucose Levels in a Sample of Children with Type 1 Diabetes

The present study explores accuracy in estimating blood glucose levels (BGL) in children with type 1 diabetes and analyzes the kinds of symptoms and cues which they use to estimate their BGL. Forty two children with type 1 diabetes completed a SI/IC-3 scale consisting of 28 items (22 symptoms and 6 feelings), indicating those which they perceived at the time and their intensity. They estimated their BGL and gave reasons for their estimation, before having a blood glucose level analysis performed. The results indicated great variability in the accuracy of estimating BGL. They showed failures in the correct discrimination of symptoms of hypoglycemia as well as the presence of false beliefs regarding indicative symptoms of hyperglycemia, and the absence of symptoms as an indicator for euglycemia, beliefs which provoke different and frequent errors in the estimation of BGL. Correct use of external signs is shown to be related to correct estimations of normal BGL, as well as hypoglycemia and hyperglycemia. We discuss the implications these results could have on designing psychological intervention procedures for diabetics in the form of training programs to discriminate BGL accurately, taking into account these findings and previous studies completed in the same field.

An update on the pharmacotherapy options for pediatric diabetes

INTRODUCTION

Diabetes mellitus is a frequent endocrine disease during childhood and adolescence. Achieving a good glycemic control is of paramount importance to avoid short- and long-term complications and to allow a normal growth and quality of life.

AREAS COVERED

This review offers an update on current available treatment strategies for type 1 and type 2 diabetes approved for use in children and adolescents.

EXPERT OPINION

Although many progresses have been made in the field of diabetes management in children and adolescents, there are still several problems to deal with. With regard to type 1 diabetes, insulin remains the main and essential therapeutic strategy. However, the main issue is to develop a system that allows more physiological insulin coverage and reduces the risk of hypoglycemia and weight gain. Adjunct therapies would be invaluable for patients struggling to achieve an acceptable glycemic control. Treatment of type 2 diabetes is based on lifestyle interventions and metformin is the first-line drug for children older than 10 years. As for type 1 diabetes, there is a strong need for developing new drugs to be used alone or in combination.

Goal disturbance and coping in children with type I diabetes mellitus: relationships with health-related quality of life and A1C

OBJECTIVE

Our first objective was to compare the health-related quality of life (HRQoL) of children with type 1 diabetes mellitus (8-12 years) with that of a healthy reference group, and to compare glycated hemoglobin (A1C) values of these children to recommended guidelines. Our second objective was to examine how goal disturbance and coping behaviour were related to HRQoL and A1C.

METHOD

Forty-three children, 8-12 years of age, completed a set of questionnaires that assessed generic and diabetes-specific HRQoL, goal disturbance and coping behaviour. Demographic and clinical characteristics were extracted from medical records.

RESULTS

Children with type 1 diabetes reported lower psychosocial HRQoL than healthy references (d=-0.48), especially on emotional functioning (d=-0.58). Goal disturbance was associated with lower generic HRQoL. Furthermore, the coping strategies avoidance, emotional reaction and wishful thinking were negatively associated with lower generic and disease-specific HRQoL (r ranged from -0.33 to -0.65), whereas acceptance was positively associated with disease-specific HRQoL (r=0.36). The average A1C was with 8.1% significantly above the recommended guidelines of 7.5%. Moreover, the coping strategies avoidance (r=0.31) and emotional reaction (r=0.32) were positively associated with higher blood glucose levels.

CONCLUSIONS

The psychosocial HRQoL of children with type 1 diabetes was affected, which was directly associated with the inability to reach personal goals (goal disturbance). An accepting coping strategy might solve these HRQoL problems and additionally improve A1C values.

Lower HbA1c after 1 year, in children with type 1 diabetes treated with insulin glargine vs. NPH insulin from diagnosis: a retrospective study

OBJECTIVE

Insulin glargine offers sustained insulin delivery for 24 h. Change to glargine treatment consistently results in lower fasting glucose and fewer hypoglycemic episodes in children with type 1 diabetes compared to continuation of NPH, although glargine has not been shown to improve HbA1c in randomized trials. Studies comparing glargine and NPH in multiple injection therapy in children treated from diagnosis of type 1 diabetes are lacking.

METHODS

HbA1c and insulin requirement were compared in a retrospective study of children (7-17 yr of age) with type 1 diabetes treated from diagnosis with basal insulin glargine (n = 49) or NPH (n = 49) in a multiple injection therapy (MIT) regimen with a rapid-acting insulin analogue. Patients were followed every third month for 1 yr. HbA1c, insulin dose, and weight data were retrieved.

RESULTS

HbA1c (mean ± SD) was lower at 3-5 months (5.5 ± 0.89 vs. 6.2 ± 0.89%, p < 0.05) and 6-9 months (5.6 ± 1.14 vs. 6.6 ± 0.99%; p < 0.001) in glargine treated. After 12 months, HbA1c was significantly lower in glargine treated (6.3 ± 1.56 vs. 7.1 ± 1.28; p < 0.01). Reported total insulin doses were similar at nadir (0.5 U/kg BW × 24 h), but significantly lower at 12 months in glargine treated (0.64 ± 0.23 vs. 0.86 ± 0.3 U/kg BW × 24 h; p < 0.001).

CONCLUSIONS

HbA1c 1 yr from diagnosis was lower in children treated with glargine from start as compared with those on NPH. This observation should be viewed in the light of a significantly lower dose of total daily insulin in the glargine group.

Health-related quality of life (HRQoL) of children with type 1 diabetes mellitus (T1DM): self and parental perceptions

The aim of the study was to evaluate health-related quality of life (HRQoL) in children and adolescents with type 1 diabetes mellitus (T1DM) in Greece compared with healthy controls and to identify the effect of age, gender, age of onset of disease, and metabolic control on perceptions of HRQoL. A total of 117 children and adolescents with T1DM aged 5-18, their parents, and 128 matched healthy children and adolescents participated. Children and adolescents completed PedsQL™ 4.0 Generic Core Scales. Children and adolescents with T1DM also completed the PedsQL™ 3.0 Diabetes Module, while their parents completed the proxy-reports of both the PedsQL™ 4.0 Generic Core Scales and the PedsQL™ 3.0 Diabetes Module. The results demonstrated that children and adolescents with T1DM had lower general HRQoL compared with healthy matched children and adolescents. Parents of children and adolescents with diabetes reported that the illness has a greater affect on their children's lives than the children themselves. Finally, the results indicated that later age of onset of diabetes, less hyperglycemic episodes, lower glycosylated hemoglobin (HbA1c), older age, and male gender were associated with better general HRQoL and diabetes-specific HRQoL. The findings have implications for designing effective therapeutic interventions aimed at improving the HRQoL of children and adolescents with T1DM.

Systematic review of communication technologies to promote access and engagement of young people with diabetes into healthcare

BACKGROUND

Research has investigated whether communication technologies (e.g. mobile telephony, forums, email) can be used to transfer digital information between healthcare professionals and young people who live with diabetes. The systematic review evaluates the effectiveness and impact of these technologies on communication.

METHODS

Nine electronic databases were searched. Technologies were described and a narrative synthesis of all studies was undertaken.

RESULTS

Of 20,925 publications identified, 19 met the inclusion criteria, with 18 technologies assessed. Five categories of communication technologies were identified: video-and tele-conferencing (n = 2); mobile telephony (n = 3); telephone support (n = 3); novel electronic communication devices for transferring clinical information (n = 10); and web-based discussion boards (n = 1). Ten studies showed a positive improvement in HbA1c following the intervention with four studies reporting detrimental increases in HbA1c levels. In fifteen studies communication technologies increased the frequency of contact between patient and healthcare professional. Findings were inconsistent of an association between improvements in HbA1c and increased contact. Limited evidence was available concerning behavioural and care coordination outcomes, although improvement in quality of life, patient-caregiver interaction, self-care and metabolic transmission were reported for some communication technologies.

CONCLUSIONS

The breadth of study design and types of technologies reported make the magnitude of benefit and their effects on health difficult to determine. While communication technologies may increase the frequency of contact between patient and health care professional, it remains unclear whether this results in improved outcomes and is often the basis of the intervention itself. Further research is needed to explore the effectiveness and cost effectiveness of increasing the use of communication technologies between young people and healthcare professionals.

Pegvisomant: current and potential novel therapeutic applications

BACKGROUND

Pegvisomant is a genetically engineered molecule, which exhibits specific growth hormone (GH) antagonism by directly interacting with the GH receptor. It is currently licensed for the treatment of acromegaly where surgery and medical therapy with somatostatin analogues have failed.

OBJECTIVE

To delineate the role of pegvisomant in the treatment of acromegaly and its novel application in other areas of clinical medicine where suppression of GH action may be of therapeutic benefit.

METHODS

A literature review from PubMed- and EMBASE-listed publications and the web-sites of licensing organisations for medicinal products.

CONCLUSION

Pegvisomant is currently used as a second line therapy in the management of acromegaly. It is highly effective in suppressing the metabolic effects of elevated GH levels when used alone or in combination with somatostatin analogues. However, its long term efficacy and safety for this indication has yet to be established. Preliminary data indicate that pegvisomant may have a role in management of type 1 diabetes with beneficial effects on insulin sensitivity and in preventing the progression of microvascular complications. Additional roles as an adjunct to cancer chemotherapy regimens and for the diagnosis of GH deficiency have been proposed, but have yet to be confirmed.

Prevention and treatment of microvascular disease in childhood type 1 diabetes

INTRODUCTION

The incidence of type 1 diabetes (T1D) is increasing worldwide, particularly in children, and is associated with a significant burden, mainly related to the development of vascular complications. The prevention and treatment of microvascular complications, which include nephropathy, retinopathy and neuropathy, are of paramount importance to decrease the associated mortality and morbidity.

SOURCES OF DATA

A literature search was performed on Medline and articles on microvascular complications, with particular emphasis on the increasing incidence of childhood T1D and its implications on prevention and treatment of complications, were selected.

AREAS OF AGREEMENT

The incidence of childhood T1D is increasing. Early identification of subjects at risk for long-term complications and early implementation of preventive and therapeutic strategies are fundamental in order to reduce the burden associated with microvascular complications of diabetes. Improving glycaemic control is the principle way of preventing and treating T1D complications.

AREAS OF CONTROVERSY

In adults with T1D and microvascular complications, treatment with anti-hypertensive drugs and statins is increasingly common, whereas there are no definitive indications for treatment with these drugs in children and adolescents with early signs of complications.

GROWING POINTS

There is growing interest in the development of new preventive and therapeutic strategies targeting specific pathways implicated in the pathogenesis of microvascular complications.

AREAS TIMELY FOR DEVELOPING RESEARCH

Investigations to clarify genetic and environmental factors implicated in the pathogenesis of microvascular complications could lead to the identification of biochemical markers with high predictive values, to be used as a guide for screening and intervention programmes.

Adolescent type 1 Diabetes Cardio-renal Intervention Trial (AdDIT)

BACKGROUND

The prognosis for young people diagnosed with diabetes during childhood remains poor and this is mainly related to the long-term risk of developing vascular complications.Microalbuminuria identifies subjects at risk for diabetic nephropathy (DN) and cardiovascular disease (CVD). It is often detected in adolescence but is rarely treated before the age of 18 years, as at the end of puberty albumin excretion may decline and in some subjects will return into the normal range. However, evidence indicates that subjects with both transient and persistent microalbuminuria have experienced renal damage during puberty and thus reno-protection to prevent long-term complications is warranted. In adults with diabetes and microalbuminuria, the use of angiotensin converting enzyme inhibitors (ACEI) and Statins is increasing, and in order to determine whether these agents are of value in the adolescent population a large randomized controlled clinical trial is needed.

METHODS/DESIGN

The Adolescent type 1 Diabetes cardio-renal Intervention Trial (AdDIT) is a multi-center, randomized, double-blind, placebo-controlled trial of ACEI and Statin therapy in adolescents with type 1 diabetes. 500 high-risk adolescents, defined on the basis of their albumin excretion, are randomized to receive either ACEI (Quinapril) or Statins (Atorvastatin) or combination therapy or placebo for 3-4 years. There will also be a parallel open observational study, based on the follow-up of 400 low-risk non-randomized adolescents. The major endpoint of the study is the change in albumin excretion; secondary endpoints include markers of CVD, renal function, retinopathy, quality of life combined with assessment of compliance and potential health economic benefits.

DISCUSSION

AdDIT will provide important data on the potential renal and cardiovascular protective effects of ACEI and Statins in high-risk adolescents. Long-term follow-up of the randomized subjects will provide direct evidence of disease outcomes, in addition to the data on early surrogate measures of DN and CVD. Follow-up of non-randomized low-risk subjects will determine the potential impact of intervention on DN and CVD. AdDIT will help to determine whether, in addition to encouraging young people to achieve good glycaemic control, pharmacological cardio-renal protection should also be implemented. EUDRACT NUMBER: 2007-001039-72

TRIAL REGISTRATION NUMBER

ISRCTN91419926.

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.

Glycaemic control and hypoglycaemia in children, adolescents and young adults with unstable type 1 diabetes mellitus treated with insulin glargine or intermediate-acting insulin

In this open study of clinical practice, 142 paediatric patients with type 1 diabetes mellitus (>1 year duration), stratified by age, received prandial insulin (regular or lispro) and either once daily insulin glargine (GLAR; n=74), titrated to target fasting blood glucose (FBG) levels 4.4-7.8 mmol/l, or NPH/semilente insulin (NPH insulin, administered once, twice or three times daily; n=68), titrated to target FBG 4.4-8.9 mmol/l. Both groups were treated for 20 +/- 10 months. HbA(1c) significantly increased in GLAR (7.3 +/- 1.0% to 7.6 +/- 1.1%; p = 0.003) and NPH/semilente insulin (7.7 +/- 1.6% to 8.3 +/- 1.5%; p = 0.0001) treated patients. The incidence of symptomatic hypoglycaemia was comparable between GLAR versus NPH/semilente insulin at endpoint (2.19 vs. 1.94 episodes/week); however, the overall incidence of severe hypoglycaemia was significantly lower with GLAR versus NPH/semilente insulin (0.14 vs. 0.73 events/patient-year; p = 0.002). The daily insulin dose was similar between the treatment groups; however, perceived quality of life (QoL) was better with GLAR. GLAR is associated with equivalent glycaemic control, less severe hypoglycaemia and improved QoL compared with NPH/semilente insulin.

Comparison of usability and patient preference for the new disposable insulin device solostar versus flexpen, lilly disposable pen, and a prototype pen: an open-label study

BACKGROUND

Patients with diabetes have been found to have a preference for insulin pens over a vial and syringe since these devices offer improvements in compliance, freedom, and flexibility.

OBJECTIVE

This study assessed the usability, specific pen features, and patient preference for 4 prefilled, disposable, insulin pens: Solostar, Humulin/Humalog pen (Lilly pen), FlexPen, and a fourth, prototype pen, Pen X, in patients with type 1 or 2 diabetes. In 1-hour interviews, patients carried out simulated use (preparing the pens, setting a dose, and injecting into a receptacle, not the body) under observation, and answered qualitative and quantitative questions. Patients were supplied with the relevant user manual. The usability (ability and time taken to carry out handling tasks) and preference (based on 14 key pen features and overall preference) of each pen were assessed without blinding for pen make/manufacturer. During the interviews, the patients prepared each pen and performed injections into a receptacle. Comparisons were made between the pens at every step. Subgroup analyses of the usability exercises were carried out based on age (11-15 years; >/=60 years), previous pen experience, and disability (visual and dexterity).

RESULTS

In total, 510 diabetes patients (65% type 2 diabetes; 51% female; mean age, 43 years [range, 11-82 years]) from 4 countries (United States, Germany, France, and Japan) completed the study. Overall, a greater proportion of patients correctly prepared the pen and performed an injection into a receptacle with Solostar versus all comparator pens (P < 0.05). Similar findings were observed in the usability subgroup analyses based on age, previous pen experience, and visual/dexterity disabilities. A significantly (P < 0.05) higher proportion of patients expressed overall preference for Solostar (53%) versus FlexPen (31%) or Lilly pen (15%).

CONCLUSION

Of the 4 pens compared, both the Solostar pen and FlexPen were found to have high patient usability, and the new Solostar pen was found to have high patient preference in these patients with diabetes.

Can we identify adolescents at high risk for nephropathy before the development of microalbuminuria?

AIMS

To determine whether higher than average albumin excretion during early puberty identifies subjects who will subsequently develop microalbuminuria (MA) and clinical proteinuria.

METHODS

Longitudinal data from the Oxford Regional Prospective Study of Childhood Diabetes (ORPS; n = 554, median duration of follow-up 10 years; range 3.0-16.7) with assessment of albumin/creatinine ratios in three early morning urine samples collected annually. An albumin excretion phenotype was derived from longitudinal data, for each individual, defining deviation from the mean of regression models, including covariates gender, age, duration of diabetes and age at assessment. Tracking of the phenotypes was confirmed in a second independent cohort from Perth, Australia.

RESULTS

The albumin excretion phenotype showed reasonable correlation between age 11-15 years and age 16-18 years in both cohorts, indicative of good 'tracking'. In the ORPS cohort, tertiles of the albumin excretion phenotype at aged 11-15 years were predictive of subsequent risk for the development of MA. All of the subjects developing clinical proteinuria had an albumin excretion phenotype in the upper tertile or an HbA(1c) > 9% at aged 11-15 years.

CONCLUSIONS

Identification of adolescents at risk of diabetic nephropathy using an albumin excretion phenotype is feasible. When combined with elevated HbA(1c), it may identify subjects for trial of early intervention with angiotensin-converting enzyme inhibitors/angiotensin-II receptor antagonists and statins to improve long-term prognosis in these subjects where sustained improvement in glycaemic control may be difficult to achieve.

Therapy with insulin glargine (Lantus) in toddlers, children and adolescents with type 1 diabetes

OBJECTIVE

To determine the efficacy and safety of insulin glargine (IG) in children and adolescents with type 1 diabetes. In a prospective, 6-month study, 80 patients, aged 2-19 years, received IG once daily plus insulin regular or rapid analogue before meals. The data of body mass index, frequency of severe hypoglycaemia, daily mean blood glucose, fasting blood glucose, haemoglobin A1c and total daily insulin dosage before and after institution of glargine therapy were collected.

RESULTS

After 6 months, the average HbA1c level in the entire cohort dropped from 7.63+/-0.81 to 7.14+/-0.70% (p<0.001). Fasting blood glucose decreased from 161+/-37 to 150+/-35 mg/dl (p<0.05) in the total group. Severe hypoglycaemic episodes were reduced from 0.18 events per patient in the 6 months before IG therapy to 0.11 events per patient in the 6 months after IG therapy. The total daily insulin dose was reduced in the entire group from 0.90+/-0.32 to 0.83+/-0.29 u/kg/day (p<0.05). Body mass index (BMI) remained unchanged. In the 14 preschooler children, the HbA1c dropped from 7.54+/-0.60 to 6.96+/-0.57% (p<0.05).

CONCLUSIONS

Insulin glargine is an efficacious treatment to improve metabolic control in children and adolescents with type 1 diabetes. It also improved the metabolic control in preschool-age children, without increasing the number of hypoglycaemic events.

Benefits of continuous subcutaneous insulin infusion in children with type 1 diabetes

OBJECTIVE

To examine the effect of continuous subcutaneous insulin infusion (CSII) therapy on parameters affecting long-term outcome in type 1 diabetes. Study design Height, weight, body mass index, insulin dose, glycosylated hemoglobin (HbA(1C)), and blood glucose data from home meter downloads were collected prospectively for analysis in 51 children (age, 10.7+/-3.1 years, mean+/-SD) throughout the 12 months before and after introducing CSII.

RESULTS

Before pump initiation, HbA(1C) was relatively stable, but it fell to 7.7+/-0.2% (P<.001) within 3 months of CSII and remained decreased (7.9+/-0.1%) at 12 months (P<.01). In contrast, weight standard deviation score increased before CSII (from 0.50+/-0.13 to 0.60+/-0.13, P<.05), but remained unchanged (0.61+/-0.11) in the year thereafter. Although severe hypoglycemia (<50 mg/dL) was reduced in the entire cohort, HbA(1C) improved primarily in young children and teenagers. Comparison of glycemic responders (HbA(1C) <7.5, or a decrease >1% on CSII, n=23) with nonresponders demonstrated no differences with respect to gender, socioeconomic status, weight standard deviation score, body mass index, initial HbA(1C), frequency of hypoglycemia, or number of education visits before CSII.

CONCLUSION

Continuous subcutaneous insulin infusion is effective in lowering HbA(1C) and the occurrence of severe nocturnal hypoglycemia without excessive weight gain in most children with type 1 diabetes. HbA(1C) response to CSII is poorer in preadolescents than in young children or teenagers.

The effects of a specific growth hormone antagonist on overnight insulin requirements and insulin sensitivity in young adults with Type 1 diabetes mellitus

AIMS/HYPOTHESIS

Growth hormone hypersecretion in Type 1 diabetes could exacerbate insulin resistance and contribute to declining glycaemic control. Our aim was to determine the effects of specific growth hormone blockade on insulin sensitivity and lipolysis in young adults with Type 1 diabetes.

METHODS

We studied the effects of two doses of a specific growth hormone antagonist (B2036-PEG; Somavert, Pharmacia Corporation, Milton Keynes, UK) on insulin sensitivity in seven young adults (17-22 yrs, 3M) with Type 1 diabetes. Subjects received 5 and 10 mg B2036-PEG, in random order for 3 weeks, with a 3-week washout. At baseline and following each treatment block, an overnight (03:00 to 08:00 h) insulin infusion for euglycaemia (5 mmol/l), followed by two-step hyperinsulinaemic euglycaemic clamp, using [6,6 2H2] glucose and 2H5 glycerol to measure glucose and glycerol turnover was performed.

RESULTS

Compared to baseline, overnight insulin requirements decreased with both doses: (means+/-SEM) 0.34+/-0.02 mU/Kg/min vs 0.25+/-0.01 (5 mg) (p=0.04), and 0.24+/-0.01 (10 mg) (p=0.004). IGF-I (ng/ml) decreased following 10 mg [223.5+/-23.9 vs 154.6+/-28.1 (p=0.005], but not 5 mg. Mean overnight non esterified fatty acid concentrations (mmol/l) decreased with 10 mg [0.51+/-0.04 vs 0.38+/-0.04 (p=0.03)], as did beta-hydroxybutyrate (mmol/l); [0.31+/-0.04 vs 0.15+/-0.02 (p=0.004)]. Glycerol production rate, an index of lipolysis, was lower following 10 mg (p=0.04), but insulin sensitivity during the clamp did not change with either dose.

CONCLUSION/INTERPRETATION

Treatment with both doses of B2036-PEG reduced overnight insulin requirements. The 10 mg dose suppressed lipolysis and reduced IGF-I. Failure to show enhanced insulin sensitivity during the clamp with the 10 mg dose could reflect opposing actions of growth hormone and IGF-I.

Randomized cross-over trial of insulin glargine plus lispro or NPH insulin plus regular human insulin in adolescents with type 1 diabetes on intensive insulin regimens

OBJECTIVE

To compare blood glucose control and incidence of nocturnal hypoglycemia in adolescents with type 1 diabetes on multiple injection regimens managed with either an insulin analog combination or NPH insulin plus regular human insulin.

RESEARCH DESIGN AND METHODS

In a randomized cross-over study, 28 adolescents with type 1 diabetes on multiple injection therapy received either insulin glargine prebedtime plus lispro preprandially (LIS/GLAR) or NPH insulin prebedtime plus regular human insulin preprandially (R/NPH). During each 16-week treatment arm, subjects completed home blood glucose profiles, and at the end of each treatment arm, they were admitted for an overnight metabolic profile. A total of 25 subjects completed the study.

RESULTS

Compared with R/NPH therapy, LIS/GLAR was associated with lower mean blood glucose levels (LIS/GLAR versus R/NPH): fasting (8.0 vs. 9.2 mmol/l, P < 0.0001), 2 h postbreakfast (8.1 vs. 10.7 mmol/l, P < 0.0005), prelunch (8.9 vs. 10.1 mmol/l, P < 0.01), and 2 h postlunch (8.0 vs. 9.5 mmol/l, P < 0.002). However, there was no difference in mean blood glucose levels before or after the evening meal. Incidence of nocturnal hypoglycemia on overnight profiles was 43% lower on LIS/GLAR compared with R/NPH therapy; however, there was no difference in rates of self-reported symptomatic hypoglycemia. Total insulin dose required to achieve target blood glucose control was lower on LIS/GLAR (1.16 IU/kg) compared with R/NPH therapy (1.26 IU/kg, P < 0.005), but there was no significant difference in HbA(1c) levels (LIS/GLAR versus R/NPH: 8.7 vs. 9.1%, P = 0.13).

CONCLUSIONS

Combination therapy with insulin glargine plus lispro reduced the incidence of nocturnal hypoglycemia and was at least as effective as R/NPH insulin therapy in maintaining glycemic control in adolescents on multiple injection regimens.

A mathematical model for pattern of change in beta-cell reserve and factors affecting residual reserve within the first 2 years of type 1 diabetes

The aim of this study was to investigate the effects of age, duration of diabetes, sex and ICA (Islet cell cytoplasmic antibody) on beta-cell reserves and to develop a model within the first 2 years of Type 1 diabetes. Beta-cell reserve is evaluated as fasting (FCp) and 1 mg i.v. glucagon stimulated C-peptide (SCp) levels in 58 Type 1 diabetics and in 12 normoglycemic subjects. Patients were divided into 3 groups according to duration of diabetes: Group I (2.5+/-0.3 weeks), Group II (13.4+/-1.2 months) and Group III (24.2+/-1.8 months). FCp/SCp level in nmol/l (mean+/-SE) were as follows. Group I: 0.21+/-0.02/0.38+/-0.04, Group II: 0.15+/-0.01/0.27+/-0.02, Group III: 0.07+/-0.01/0.11+/-0.02, CONTROL GROUP: 0.42+/-0.09/1.29+/-0.13. The scatter plots of C-peptide levels vs time in all the diabetic patients fitted in to a 4th-order polynomial regression (R: 0.96-0.98). Age was strongly correlated with FCp (rs: 0.46, p<0.05) and ICA positivity affected Cp-levels negatively (p>0.05). In conclusion, as the duration of diabetes increases, response time to glucagon prolongs and amplitude of it shortens. Duration of diabetes of less than 2 weeks, feminity, puberty and ICA positivity affect beta-cell reserve negatively, conversely, masculinity, post-puberty, older age and ICA negativity affect the reserve positively. The dynamics of C-peptide response to glucagon follow a mathematical model and Type 1 diabetes causes a decrease not only in the amplitude of the response but also in the duration of the response.

Current methods of transfer of young people with Type 1 diabetes to adult services

AIMS

To determine the efficacy and patient perception of various transfer procedures from paediatric to adult diabetes services.

METHODS

Comparison between four districts in the Oxford Region employing different transfer methods, by retrospective study of case records and interviews of patients recently transferred from paediatric diabetes clinics. The main outcome measures were age at transfer, clinic attendance rates, HbA1c measurements and questionnaire responses.

RESULTS

Two hundred and twenty-nine subjects (57% males) > 18 years old in 1998 and diagnosed with Type 1 diabetes < 16 years of age between 1985 and 1995, identified from the regional diabetes register. The notes audit was completed for 222 (97%) and 164 (72%) were interviewed by a single research nurse. Mean age at transfer was 17.9 years (range 13.3-22.4 years). Few young people were lost to follow-up at the point of transfer. There was a high rate of clinic attendance (at least 6 monthly) 2 years pretransfer (94%), but this declined to 57% 2 years post-transfer (P < 0.0005). There was large interdistrict variation in clinic attendance 2 years post-transfer (29% to 71%); higher rates were seen in districts where young people had the opportunity to meet the adult diabetes consultant prior to transfer. The importance of this opportunity was confirmed by questionnaire responses on interview.

CONCLUSIONS

Adolescence is a vulnerable period for patients with diabetes. This regional survey demonstrated a marked decline in clinic attendance around the time of transition from paediatric to adult services. The reasons are complex, but mode of transfer may be an important factor.

Treatment of hypertension and microalbuminuria in children and adolescents with type 1 diabetes mellitus

Nephropathy is the main cause of morbidity and mortality in patients with type 1 diabetes and, in adults, persistent microalbuminuria is the best marker of the consequent risk for its development. In the pediatric population, puberty represents the most important risk factor for the development of microangiopathic complications, although it is not necessarily associated with the progression to frank proteinuria. As many as 50% of subjects may revert to normoalbuminuria. Hypertension is a further risk factor and may accelerate the progression of micro- and macrovascular complications. There is evidence that angiotensin-converting enzyme (ACE) inhibitors reduce renal damage by one or more mechanisms independent of their antihypertensive effects--hence they represent the drug of choice for the treatment of diabetic nephropathy. However, as angiotensin II receptor antagonists are more specific, they may become the obvious treatment choice in the near future. There is no consensus as to who should be treated and when treatment with renoprotective drugs should begin in the pediatric population, due to the lack of a clear definition of the natural history of microalbuminuria in this age group. In this review some models and controversial aspects of this issue are presented and discussed.

Development according to pubertal stage in Brazilian children and adolescents with short-term diabetes

The anthropometric status and metabolic control of 51 recently diagnosed Brazilian schoolchildren with type 1 diabetes (DM1), during the first 5 years of the disease, were compared with those of normal children (60 girls and 132 boys) belonging to the same environmental condition and pubertal stage. Metabolic control was evaluated on the basis of fasting plasma glucose (FPG) and HbA1c levels. The criteria of the National Center for Health Statistics were used for anthropometric evaluation. FPG (205 +/- 51 mg/dl for girls vs 200 +/- 34 mg/dl for boys) and % above upper normal limit of median HbA1c (1.8% for girls vs 2.5% for boys with diabetes) were not significantly different during follow-up. The Z-score of the last height evaluation was lower in the girls' group (-0.14 vs -0.53, P<0.05). By forward stepwise analysis, the Z-score of the initial height was statistically significant as a determinant factor for height at the end of the study in both girls and boys with DM1. The Z-score of weight at last evaluation was not different from that at diagnosis in either sex. However, analysis according to pubertal stage showed a tendency to a weight increase in the girls. The weight recovery and height loss in girls with DM1 follows the trend of the normal Brazilian population.

Clinical and psychological course of diabetes from adolescence to young adulthood: a longitudinal cohort study

OBJECTIVE

To determine the clinical and psychological course of diabetes through adolescence and the relationship with glycemic control in young adulthood.

RESEARCH DESIGN AND METHODS

A longitudinal cohort study of adolescents recruited from the register of the outpatient pediatric diabetes clinic. A total of 76 individuals (43 male patients, 33 female patients) aged 11-18 years completed baseline assessments, and 65 individuals (86%) were reinterviewed as young adults (20-28 years of age). Longitudinal assessments were made of glycemic control (HbA(1c)), weight gain (BMI), and development of complications. Adolescents completed self-report questionnaires to assess emotional and behavioral problems as well as self-esteem. As young adults, psychological state was assessed by the Revised Clinical Interview Schedule and the self-report Brief Symptom Inventory.

RESULTS

Mean HbA(1c) levels peaked in late adolescence and were worse in female participants (average 11.1% at 18-19 years of age). The proportion of individuals who were overweight (BMI >25.0 kg/m(2)) increased during the 8-year period from 21 to 54% in female patients and from 2 to 28% in male patients. Serious diabetes-related events included death in one patient and cognitive impairment in two patients. Individuals in whom diabetic complications developed (25% of male patients and 38% of female patients) had significantly higher mean HbA(1c) levels than those without complications (difference 1.9%, 95% CI 1.1-2.7, P < 0.0001). Behavioral problems at baseline were related to higher mean HbA(1c) during the subsequent 8 years (beta = 0.15, SEM (beta) 0.04, P < 0.001, 95% CI 0.07-0.24).

CONCLUSIONS

The outcome for this cohort was generally poor. Behavioral problems in adolescence seem to be important in influencing later glycemic control.

The role of IGF-binding proteins in mediating the effects of recombinant human IGF-I on insulin requirements in type 1 diabetes mellitus

To determine the role of IGF-binding proteins in mediating the direct effects of recombinant human IGF-I on insulin requirements in type 1(insulin-dependent) diabetes mellitus, overnight changes in IGF-I, IGF-II, and IGF-binding protein-1, -2, and -3, collected under euglycemic conditions, were compared in nine subjects after double blind, randomized, sc administration of recombinant human IGF-I (40 microg/kg) or placebo at 1800 h. On both nights a somatostatin analog infusion (300 ng/kg x h) suppressed endogenous GH production, and three timed discrete GH pulses (total, 0.029 IU/kg x night) ensured identical GH levels. After recombinant human IGF-I administration, IGF-I levels and the IGF-I/IGF-binding protein-3 ratio increased [mean +/- SEM:IGF-I, 401 +/- 22 ng/ml; placebo, 256 +/- 20 ng/ml (P = 0.0002); IGF-I, 0.108 +/- 0.006; placebo, 0.074 +/- 0.004 (P = 0.0003), respectively], and insulin requirements decreased (IGF-I, 0.12 +/- 0.03; placebo, 0.23 +/- 0.03 U/kg x min; P = 0.008). The normal within-individual inverse relationships between insulin and IGF-binding protein-1 levels were observed (lag time 2 h: r = -0.34; P < 0.01). Yet despite reduced free insulin levels (8.5 +/- 1.5; placebo, 12.2 +/- 1.2 mU/liter; P = 0.03), IGF-binding protein-1 levels were reduced after recombinant human IGF-I administration (53.7 +/- 6.8; placebo, 82.2 +/- 11.8 ng/ml; P = 0.008). The largest reductions in free insulin levels after recombinant human IGF-I and thus putative improvement in insulin sensitivity occurred in subjects with the smallest increase in the plasma IGF-I/IGF-binding protein-3 ratio (r = 0.7; P = 0.03). Taken together, these data are consistent with the hypothesis that transcapillary movement of IGF-I (perhaps mediated by IGF-binding protein-1), out of the circulation facilitates altered insulin sensitivity. These data have important implications for risk-benefit assessment of recombinant human IGF-I therapy in type 1 diabetes mellitus.

Elevated leptin levels are associated with excess gains in fat mass in girls, but not boys, with type 1 diabetes: longitudinal study during adolescence

Adolescents, in particular girls, with type 1 diabetes may gain excessive weight during puberty. We present the results of a longitudinal study aimed to determine the roles of leptin and insulin in changes in body composition in subjects with type 1 diabetes and controls. Forty-six children (23 boys) with type 1 diabetes and 40 controls (20 boys) were followed from 8-17 yr of age. Height, weight, and sc skinfolds were assessed every 6 months, and a blood sample taken for leptin determination. Throughout the age range, body mass index (mean +/- SEM) was greater by 1.45 +/- 0.69 kg/m(2) in girls and 1.46 +/- 0.55 kg/m(2) in boys with type 1 diabetes compared with control values. In girls with type 1 diabetes, this reflected greater percent body fat (3.2 +/- 1.0%; P = 0.002), whereas in boys it related to differences in fat-free mass. Both boys and girls with type 1 diabetes had higher leptin levels adjusted for percent body fat than controls; in the girls this was related to insulin dose (regression coefficient B = 0.006 +/- 0.003; P = 0.04) and greater gains in fat mass. Hyperinsulinemia and raised leptin levels are associated with gains in fat mass throughout puberty in girls, but not boys, with type 1 diabetes.

Increased 24 h mean insulin-like growth factor binding protein-3 proteolytic activity in pubertal type 1 diabetic boys

Hyperglycaemia and increased variability of blood glucose in pubertal children with type 1 diabetes may be related to increased growth hormone (GH) secretion and insulin resistance. The role of changes in insulin-like growth factor-I (IGF-I) bioavailability for the glycaemic control in these patients has not been completely elucidated. In particular, the possible role of increased IGF binding protein-3 (IGFBP-3) proteolysis reported in other insulin resistant states awaits further characterization. The aims of this study were to assess if hyperglycaemia in children with type 1 diabetes was associated with changes in free dissociable IGF-I (fdIGF-I) and IGF binding protein-3 protease activity (IGFBP-3-PA) and if increased insulin resistance during puberty was associated with changes in IGFBP-3-PA in healthy and diabetic children. In diabetic boys in the period of maximal linear growth (Tanner stage 3, n = 5), the mean level and the variability of IGFBP-3-PA, determined every second hour throughout 24 h, were significantly higher both compared to postpubertal diabetic boys (n = 6; P = 0.003 and P = 0.001, respectively), and to age matched healthy boys (n = 4; P = 0.006 and P < 0.001 respectively). This activation of IGFBP-3-PA was most prominent during the day time. The mean 24 h blood glucose level (determined hourly) was the only parameter studied that significantly predicted the changes in mean 24 h IGFBP-3-PA in the diabetes group. The mean 24 h concentrations of fdIGF-I were decreased in the diabetic boys compared to the healthy controls but statistical significance was only achieved in Tanner Stage 5 (p = 0.03). We speculate that the elevated levels of IGFBP-3-PA in Tanner 3 diabetic boys are related to deteriorated glucose homeostasis and that it may be a compensatory mechanism to attenuate the decrease in fdIGF-I in order to partly restore insulin sensitivity and glycemic control.

Serum androgen levels in adolescents with type 1 diabetes: relationship to pubertal stage and metabolic control

Delayed sexual maturation is still frequently seen in adolescents with type 1 diabetes. A close relationship between insulin and androgen metabolism has been found in a number of studies. Our study was designed to investigate whether or not abnormalities in androgen secretion could play a role in the onset of sexual maturation in adolescents with type 1 diabetes. We have asked whether or not there was a correlation between daily insulin dosage, duration of diabetes, metabolic control, age, pubertal stage, and body mass index (BMI) versus serum androgen concentrations. Basal total and free testosterone, dehydroepiandrosterone-sulfate (DHEA-S), dihydrotestosterone (DHT), sex hormone binding globulin (SHBG) and 3alpha-androstanediol glucuronide (3alpha diol-G) plasma concentrations were measured in 36 pubertal boys and 31 pubertal girls with type 1 diabetes and in 59 sex- and pubertal stage-matched control subjects without diabetes. Significantly higher serum total testosterone (p<0.01) and free testosterone (p<0.05) levels were found in females and males with type 1 diabetes than in controls at pubertal stage 5. DHEA-S, SHBG, DHT and 3alpha diol G concentrations in patients with diabetes were not significantly different from those in controls. There was no correlation between daily insulin requirements and serum androgen levels. These data suggest that adolescents with diabetes have similar serum levels of DHEA-S, SHBG, DHT and 3alpha diol G as healthy subjects at all stages of puberty. However, there are significant differences in serum testosterone and free testosterone levels in adolescents with diabetes when compared to healthy, sex- and pubertal stage-matched controls in late puberty. We hypothesize that the increased testosterone levels in patients with diabetes could relate to reduced fertility in females, disorders of sexual maturation and an increased risk for cardiovascular complications later in life.

Quality of paediatric IDDM care in Germany: a multicentre analysis. German Paediatric Diabetology Group

Quality management has been applied in recent years to improve the care of children and adolescents with insulin dependent diabetes mellitus (IDDM). In 1995 the German Paediatric Diabetology Working Group published standards on quality control, in which relevant parameters on structure, process and outcome of care were defined. A computer software programme-developed at the University of Ulm under the auspices of the German Secretary of Health-has been used for quality control with central anonymous analysis in a nationwide survey. Data from 23 paediatric centres with 2407 patients seen between January and June 1996 were evaluated. The results showed an admission rate to hospital of 23.8 per 100 patient-years with an average duration of in-patient stay of 2.74 days/year. 80% of the patients were treated with an intensive insulin therapy regimen comprising three or more injections daily. The overall metabolic control was reasonably good with a mean HbA1c value of 7.8%. The rate of severe hypoglycaemia complicated by coma and/or convulsions was six per 100 patient-years and of ketoacidosis one per 100 patient-years. Unfortunately screening for diabetic retinopathy and nephropathy was not carried out consistently. The incidence was 44% and 33% respectively.

Diabetic retinopathy in pediatric patients with type-1 diabetes: effect of diabetes duration, prepubertal and pubertal onset of diabetes, and metabolic control

OBJECTIVE

The objective of this study was to determine the contribution of prepubertal and pubertal onset and duration of diabetes to the development of diabetic retinopathy.

STUDY DESIGN

A total of 1391 standardized fundus examinations (stereo fundus-photography) were performed in 441 children or adolescents with type-1 diabetes (median age 15.5 years, median duration of diabetes 6.3 years).

RESULTS

Mild nonproliferative retinopathy was present in 72 patients (median age 19.9 years). Life table analysis revealed a median duration of diabetes until retinopathy was first diagnosed at 16.6 years (95% confidence interval: 15.3 to 18.3). Patients were stratified according to diabetes onset before or in puberty (> or = 10.4 years in girls, > or = 12.2 years in boys). In children with a prepubertal onset of diabetes, retinopathy occurred after a pubertal duration of 10.9 years compared with 15.1 years in children with onset of diabetes in puberty (p < 0.01), demonstrating the additional risk conveyed by the prepubertal years of diabetes. Long-term metabolic control had a significant influence on the prevalence of retinopathy: patients with a median HbA1c > or = 7.5% had development of retinopathy on average after 15.5 years compared with 18.3 years in patients with lower HbA1c values (p < 0.05).

CONCLUSION

Both prepubertal and pubertal duration of diabetes are relevant for the development of background retinopathy. Good metabolic control should be attempted irrespective of age.

Relation between insulin-like growth factor-I, body mass index, and clinical status in cystic fibrosis

OBJECTIVES

Despite improved nutrition and intensive treatment, subjects with cystic fibrosis have difficulty in maintaining anabolism during intercurrent infections, which can result in reduced body mass index and impaired skeletal growth. Insulin-like growth factor-I (IGF-I) and its binding protein IGFBP3 are sensitive to changes in nutritional status. The aim of this study was to determine the relation between circulating concentrations of these peptides, body mass index, and clinical status in cystic fibrosis.

METHODS

Serum concentrations of IGF-I and IGFBP3 were measured in 197 subjects (108 males, 89 females; mean age 9.69 years, range 0.41-17.9 years) and these data were analysed with respect to body mass index, pubertal stage, and clinical status as assessed by Shwachman score and forced expiratory volume in one second (FEV1).

RESULTS

The mean height SD score of the children studied was -0.2 (SD 1.14) and the body mass index SD score -0.26 (1.4). The body mass index SD score declined with increasing age (r = -0.18) and paralleled changes in IGF-I concentrations, which also declined. The IGF-I SD score (calculated from control data) correlated with age (r = -0.53). The abnormalities were most obvious during late puberty, when IGF-I and IGFBP3 concentrations were significantly reduced compared with those in control subjects matched for pubertal stage. The IGF-I SD score correlated with height SD score (r = 0.14) and the decline in IGF-I concentrations with the fall in body mass index SD score (r = 0.42). IGF-I SD scores also correlated with the Shwachman score (r = 0.33) and FEV1 (r = 0.17).

CONCLUSIONS

The close relation between declining IGF-I and IGFBP3 concentrations and body mass index in patients with cystic fibrosis may simply reflect poor nutritional status and insulin hyposecretion. Nevertheless, IGF-I deficiency could also contribute towards the catabolism observed in these patients, and IGF-I SD scores correlated with other measures of clinical status such as the Shwachman score and FEV1.

Insulin-like growth factor I, its binding proteins 1 and 3, and growth hormone-binding protein in children and adolescents with insulin-dependent diabetes mellitus: clinical implications

Values of IGF-I after extraction, its binding proteins, and the high affinity GH-binding protein (BP) are not well established in pediatric patients with insulin-dependent diabetes mellitus (IDDM). We report data for IGF-I, IGFBP-1, and -3, and GHBP in 92 Spanish children with IDDM, separated according to pubertal stage: prepubertal (n = 49); pubertal onset (n = 17); mid-puberty (n = 17), and complete puberty (n = 9), as well as to metabolic control (HbA1 < 9% or > or = 9%). IGF-I levels in IDDM patients increased throughout development (p < 0.001), but were diminished at every developmental stage when compared with marched control subjects. IGF-I concentrations showed a negative correlation with the degree of metabolic control, in particular during the prepubertal stage of development. A negative correlation (r = -0.22; p < 0.005) between IGF-I concentrations and HbA1 was found. Serum IGFBP-I levels diminish during maturation in diabetic patients (p < 0.001). However, IDDM patients have significantly higher levels of IGFBP-1 than control subjects at every stage of development, and IDDM patients with inadequate metabolic control exhibit even greater differences when compared with matched control subjects. A positive correlation (r = 0.22; p < 0.005) between IGFBP-1 concentrations and HbA1 was found. IGFBP-3 serum levels were similar to those observed in normal subjects, and no correlation was observed in relation to the metabolic control. In IDDM patients, GHBP levels change significantly during maturation, as they do in normal control subjects; however, significantly lower GHBP levels were found in prepubertal and pubertal IDDM patients. GHBP levels were independent of metabolic control, although a tendency toward lower levels of GHBP was seen when HbA1 levels increased. We suggest that a partial GH resistance syndrome exists in IDDM patients, and this may be related to the metabolic control. Hence, the biochemical markers measured here may be of value in evaluating the smaller pubertal growth spurt in diabetic patients.

Insulin-like growth factors (IGFs) and IGF-I treatment in the adolescent with insulin-dependent diabetes mellitus

Insulin-dependent diabetes mellitus (IDDM) during adolescence is associated with complex derangements of the growth hormone (GH)/insulin-like growth factor (IGF) axis. Despite GH hypersecretion, IGF-I levels and IGF bioactivity are reduced. The diabetogenic effects of GH are well established, and GH hypersecretion has been implicated in the deterioration in glycemic control during adolescence and in the development of microangiopathy. Insulin deficiency or reduced portal delivery of insulin plays a central role in the development of these abnormalities, and although continuous subcutaneous insulin delivery may improve plasma IGF-I levels, it does not necessarily suppress GH levels. Recombinant IGF-I has been proposed as an adjunct to conventional insulin therapy, as restoring circulating IGF-I levels might lead to GH suppression. Placebo-controlled studies have shown a consistent reduction in GH secretion and related improvements in insulin sensitivity following a single subcutaneous IGF-I injection (40 micrograms/kg). Repeated daily subcutaneous IGF-I administration for 1 month resulted in a sustained increase in IGF-I levels, as well as a reduction in GH secretion and insulin requirements. There was no increase in hypoglycemia or other adverse effects. Recombinant IGF-I used in conjunction with insulin may therefore provide an additional approach to the management of IDDM during adolescence, allowing correction of abnormalities in the GH/IGF axis and leading to improved control and, hence, reduced risk of long-term complications. However, this hypothesis needs to be rigorously tested in long-term placebo-controlled studies.

Influence of puberty on lipids and lipoprotein profile in children with type 1 diabetes mellitus

In order to assess whether or not the lipoprotein profile worsens throughout puberty in children with type 1 diabetes mellitus and if this change is related to dietary compliance, we studied 46 (20 female, 26 male) children. At the beginning of the study, the mean age (+/- SD) was 10.9 +/- 1.1 years; all the children studied had reached a pubertal stage of P1, G1. The mean duration of diabetes (+/- SD) was 4.9 +/- 1.8 years. The diet and the lipoprotein profile of diabetic children were analysed at the beginning of the study and after 6 years. The quality of metabolic control of subjects studied had not changed significantly at the end of the study (haemoglobin HbA1c 7.6% +/- 2.1% vs 7.9% +/- 2.0%; NS). After puberty, the diabetic patients received more energy from carbohydrate and less from lipids. Total serum cholesterol and triglycerides and levels of low-density lipoproteins were significantly higher and of high-density lipoproteins lower in the diabetic patients after puberty than before (4.47 +/- 0.7 mmol/l vs 5.99 +/- 0.6, P < 0.01; 0.90 +/- 0.02 mmol/l vs 1.45 +/- 0.03, P < 0.01; 2.2 +/- 0.3 mmol/l vs 2.8 +/- 0.5, P < 0.01; 1.5 +/- 0.2 vs 1.1 +/- 0.2, P < 0.01, respectively). These results suggest a detrimental effect of puberty on lipoproteins; probably, dietary compliance plays a role in this worsening. Dietary education should be intensified during adolescence in order to present these changes.

Loss of the normal relationships between growth hormone, growth hormone-binding protein and insulin-like growth factor-I in adolescents with insulin-dependent diabetes mellitus

OBJECTIVE

It has been proposed that the dissociation between growth hormone secretion and insulin-like growth factor-I (IGF-I) concentrations in insulin-dependent diabetes mellitus arises because of partial resistance at the GH receptor. In order to explore this hypothesis further we have examined the relations between IGF-I, GH-binding protein (GHBP), and GH secretion in normal subjects and patients with diabetes during puberty.

DESIGN AND SUBJECTS

Blood samples for the estimation of IGF-I and GHBP levels were obtained from 104 patients with diabetes and 89 puberty matched controls. Thirty-four of the controls and 42 of the patients with diabetes also underwent an overnight GH secretory profile with measurements of GH every 15-20 minutes between 2000 and 0800 h.

RESULTS

In multivariate analysis using sex, puberty stage, and presence or absence of diabetes as dependent variables, diabetes was associated with increased GH levels (F = 23.04, P < 0.001), reduced IGF-I (F = 10.89, P < 0.001), and reduced GHBP levels (F = 31.36, P < 0.001). A negative relation between GH and GHBP levels (r = -0.44, P < 0.01) was found in normal subjects but this was absent in those with diabetes. Both GHBP and IGF-I levels in the diabetic subjects were correlated with total insulin dose (r = 0.4, P < 0.001, and r = 0.46, P < 0.001, respectively). Yet there was no direct correlation between GHBP and IGF-I concentrations. The variation in IGF-I levels was also related to glycosylated haemoglobin levels in the diabetics (r = -0.27, P = 0.01). In a stepwise multiple regression analysis insulin dose contributed 23%, HbA1 4.4% and C-peptide levels 3.7% to the variation in IGF-I levels.

CONCLUSIONS

In adolescents with insulin dependent diabetes mellitus, the elevated GH concentrations are associated with low circulating IGF-I and GHBP concentrations and the normal reciprocal relation between GHBP and GH is no longer evident. Although IGF-I and GHBP are both related to insulin dose, there is no direct correlation between these variables. This may indicate that GHBP reflects GH receptor numbers but not necessarily post receptor events, and the weak positive correlation between GH and IGF-I indicates that increased growth hormone secretion may compensate for reduced receptor numbers.

The effects of recombinant human insulin-like growth factor I on growth hormone secretion in adolescents with insulin dependent diabetes mellitus

OBJECTIVE

It has been proposed that low IGF-I levels and reduced IGF-I bioactivity may lead to elevated GH levels in adolescents with insulin dependent diabetes (IDDM). We have therefore studied the effects of human recombinant insulin-like growth factor I (rhIGF-I) administration on GH levels and GH secretion in adolescents with IDDM.

PATIENTS

Nine late pubertal adolescents (four male and five female) with IDDM.

DESIGN

A double-blind placebo controlled study of rhIGF-I administered subcutaneously in a dose of 40 micrograms/kg body weight at 1800 h.

MEASUREMENTS

IGF-I and GH concentrations were measured at regular intervals throughout the study. Twenty-two hour GH secretory rates were calculated by deconvolution analysis. Overnight GH profiles were analysed by distribution analysis, and Fourier transformations were performed on both overnight GH concentrations and GH secretory rates.

RESULTS

Mean IGF-I levels over the 22-hour study period were significantly elevated following rhIGF-I administration (350 +/- 26 vs 205 +/- 21 micrograms/l (mean +/- SEM), P < 0.01). Mean 22-hour GH levels were reduced following rhIGF-I administration (19.4 +/- 4.0 compared with 33.6 +/- 5.8 mU/l; P = 0.01). Distribution analysis demonstrated that the reduction in GH levels was due to changes in the proportion of values at both high and low concentrations. Deconvolution analysis also revealed a significant overall reduction in GH secretory rate following IGF-I administration (1.81 +/- 0.30 vs 2.98 +/- 0.47 mU/min, P = 0.01) which was still apparent during the final 5.5 hours of the study period (1.51 +/- 0.30 vs 2.76 +/- 0.61 mU/min, P = 0.02). The dominant periodicity of GH secretory episodes as determined by Fourier transformation was between 120 and 180 minutes after both IGF-I and placebo.

CONCLUSIONS

In late pubertal adolescents with IDDM the rise in IGF-I levels following rhIGF-I administration in a subcutaneous dose of 40 micrograms/kg body weight leads to a significant reduction in GH levels and GH secretory rate. The reduction in GH secretion is due to changes in pulse amplitude rather than frequency. A reduction in GH secretion was apparent at the beginning and also towards the end of the 22-hour study period.

Growth during childhood and final height in type 1 diabetes

The growth of 184 children with Type 1 diabetes was analysed using data collected prospectively in the Oxford district between 1969 and 1992. The overall mean height standard deviation score (Ht SDS +/- SD) at diagnosis was 0.35 +/- 1.05 which was significantly greater than the national standard of Tanner (1966). However, there is evidence of a secular trend in the heights of Oxford children over the last 20 years when compared with Tanner. When data from children with diabetes were compared with local controls, it was only the children aged 5-10 years at diagnosis who were taller (Ht SDS +/- SD, 0.58 +/- 1.14, versus 0.31 +/- 0.90, n = 73, p < 0.05). Those diagnosed under the age of 5 years (n = 37) were shorter (Ht SDS 0.12 +/- 0.93) and those diagnosed aged more than 10 years (n = 74) were similar in size (Ht SDS 0.22 +/- 0.98) to controls. These differences could not be explained by social class. Loss of height occurred between diagnosis and puberty, particularly in those diagnosed between the ages of 5 and 10 years. The pubertal growth spurt was blunted in all groups but this abnormality was more profound in the girls (mean peak height velocity SDS -1.09 +/- 1.02, p < 0.0005) than in the boys (mean peak height volocity SDS -0.5 +/- 1.14, p < 0.025). The mean final height SDS was -0.74 +/- 0.96 in those diagnosed < 5 years, 0.00 +/- 1.26 in those diagnosed between the ages of 5 and 10 years and 0.09 +/- 1.10 in those aged more than 10 years at diagnosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Glycated haemoglobin centiles: a basis for audit in children's clinics?

Services for children with diabetes are a good model for audit because of relatively well-defined and available measures of outcome. Estimation of glycated haemoglobin (HbA1) is accepted as one index of control, although the assay and normal ranges vary in different centres. Sheffield has a stable clinic population and we have taken blood for HbA1 on each patient two to four times per year since 1983. HbA1 values have been aligned in 3-monthly increments from time of diagnosis to construct a graph showing the mean plus or minus two standard deviation values for the clinic population and also a rough 'centile chart' that describes the unfortunate but expected pattern of deteriorating control with duration of diabetes. There are undoubtedly methodological flaws in this novel approach; however, such charts constructed for each clinic may be a suitable basis for comparative assessment of the control of an individual and also for auditing the effects of changes in practice that strive for optimum glucose levels in the clinic population.