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Sebastian-Valles F, Martínez-Alfonso J, Arranz Martin JA, Jiménez-Díaz J, Hernando Alday I, Navas-Moreno V, Joya TA, Fandiño García MDM, Román Gómez GL, Garai Hierro J, Lander Lobariñas LE, Martínez de Icaya P, Sampedro-Nuñez MA, Martínez-Vizcaíno V, Marazuela M. Impact of socioeconomic status on chronic control and complications of type 1 diabetes mellitus in users of glucose flash systems: a follow-up study. BMC Med 2024; 22:37. [PMID: 38273326 PMCID: PMC10809494 DOI: 10.1186/s12916-024-03254-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 01/10/2024] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND This study investigates the association between socioeconomic status (SES) and glycemic control in individuals with type 1 diabetes (T1D) using flash glucose monitoring (FGM) devices within a public health system where these technologies are freely available and utilized according to recommended guidelines. METHODS A follow-up study of 1060 adults (mean age 47.4 ± 15.0 years, 49.0% women) with T1D, receiving care at three Spanish university hospitals that regularly employ the FGM system. SES was assessed using the Spanish Deprivation Index and the average annual net income per person. Glycemic data were collected over a 14-day follow-up period, including baseline glycated hemoglobin (HbA1c) levels prior to sensor placement, the last available HbA1c levels, and FGM-derived glucose metrics. Individuals with sensor usage time < 70% were excluded. Chronic micro and macrovascular complications related to diabetes were documented. Regression models, adjusted for clinical variables, were employed to determine the impact of SES on optimal sensor control (defined as time in range (TIR) ≥ 70% with time below range < 4%) and disease complications. RESULTS The average follow-up was of 2 years. The mean TIR and the percentage of individuals with optimal control were higher in individuals in the highest SES quartile (64.9% ± 17.8% and 27.9%, respectively) compared to those in the lowest SES quartile (57.8 ± 17.4% and 12.1%) (p < 0.001). Regression models showed a higher risk of suboptimal control (OR 2.27, p < 0.001) and ischemic heart disease and/or stroke (OR 3.59, p = 0.005) in the lowest SES quartile. No association was observed between SES and the risk of diabetic nephropathy and retinopathy. FGM system improved HbA1c levels across all SES quartiles. Although individuals in the highest SES quartile still achieved a significantly lower value at the end of the follow-up 55 mmol/mol (7.2%) compared to those in the lowest SES quartile 60 mmol/mol (7.6%) (p < 0.001), the significant disparities in this parameter between the various SES groups were significantly reduced after FGM technology use. CONCLUSIONS Socioeconomic status plays a significant role in glycemic control and complications in individuals with T1D, extending beyond access to technology and its proper utilization. The free utilization of FGM technology helps alleviate the impact of social inequalities on glycemic control.
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Affiliation(s)
- Fernando Sebastian-Valles
- Department of Endocrinology and Nutrition, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria de La Princesa, Universidad Autónoma de Madrid, 28006, Madrid, Spain.
| | - Julia Martínez-Alfonso
- Department of Family and Community Medicine, Centro de Salud Daroca, 28006, Madrid, Spain
| | - Jose Alfonso Arranz Martin
- Department of Endocrinology and Nutrition, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria de La Princesa, Universidad Autónoma de Madrid, 28006, Madrid, Spain
| | - Jessica Jiménez-Díaz
- Department of Endocrinology and Nutrition, Hospital Universitario Severo Ochoa, Leganés, 28194, Madrid, Spain
| | - Iñigo Hernando Alday
- Department of Endocrinology and Nutrition, Hospital Universitario Basurto, 48013, Bilbao, Spain
| | - Victor Navas-Moreno
- Department of Endocrinology and Nutrition, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria de La Princesa, Universidad Autónoma de Madrid, 28006, Madrid, Spain
| | - Teresa Armenta Joya
- Department of Endocrinology and Nutrition, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria de La Princesa, Universidad Autónoma de Madrid, 28006, Madrid, Spain
| | | | - Gisela Liz Román Gómez
- Department of Endocrinology and Nutrition, Hospital Universitario Severo Ochoa, Leganés, 28194, Madrid, Spain
| | - Jon Garai Hierro
- Department of Endocrinology and Nutrition, Hospital Universitario Basurto, 48013, Bilbao, Spain
| | | | | | - Miguel Antonio Sampedro-Nuñez
- Department of Endocrinology and Nutrition, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria de La Princesa, Universidad Autónoma de Madrid, 28006, Madrid, Spain
| | - Vicente Martínez-Vizcaíno
- Health and Social Care Research Center, Universidad de Castilla-La Mancha, 16071, Cuenca, Spain
- Facultad de Ciencias de La Salud, Universidad Autónoma de Chile, Talca, Chile
| | - Mónica Marazuela
- Department of Endocrinology and Nutrition, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria de La Princesa, Universidad Autónoma de Madrid, 28006, Madrid, Spain
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Odeyemi AO, Agelebe E, Oseni SB, Adebami OJ, Oyedeji OA. Influence of social disadvantage among children admitted to the pediatric emergency unit of a tertiary Hospital in Nigeria. Niger J Clin Pract 2022; 25:1021-1028. [DOI: 10.4103/njcp.njcp_1406_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Baechle C, Stahl-Pehe A, Castillo K, Selinski S, Holl RW, Rosenbauer J. Association of family structure with type 1 diabetes management and outcomes in adolescents: A population-based cross-sectional survey. Pediatr Diabetes 2021; 22:482-494. [PMID: 33259124 DOI: 10.1111/pedi.13166] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 09/09/2020] [Accepted: 11/11/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Diabetes therapies have enormously changed during past decades, but only few studies have analyzed the association between family structure and diabetes management and outcomes. OBJECTIVE To analyze cross-sectionally the associations of family structure with type 1 diabetes (T1D) management and various diabetes outcomes. METHODS A total of 1635 11- to 17-year-old participants and their parents completed one of three baseline surveys as part of a nationwide, population-based cohort study on early-onset, long-standing T1D. Associations between family structure and outcome variables were analyzed by multivariable linear/logistic regression. RESULTS Compared to adolescents living with both parents (reference), HbA1c was 0.48% (95% confidence interval 0.24; 0.71) / 5.2 (2.6; 7.8) mmol/mol higher in adolescents living with one parent and 0.34% (0.08; 0.59) / 3.7 (0.9; 6.5) mmol/mol higher in those living with one parent and her/his partner. The blood glucose self-monitoring (SMBG) frequency was lower (single parent: -0.6 (-1.1; -0.2), parent and partner:-0.5 (-1.0; 0.0)) and parents reported more long-term consequences related to school or work (ORsingle-parent 1.52 (0.90; 2.57), ORparent + partner 1.50 (0.86; 2.60)). While living with one parent was associated with increased odds of insulin injection vs. insulin pump therapy (OR 1.61 [1.13; 2.29]), the odds of low hypoglycemia awareness (OR 1.75 [1.00; 3.08]) and diabetes complications (1.32 [0.78; 2.22]) were higher in people living with a parent and her/his partner. CONCLUSIONS Living with only one parent with or without a new partner was associated with less SMBG and pump use and poor diabetes outcomes. Future studies to explore the underlying mechanisms are required.
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Affiliation(s)
- Christina Baechle
- German Diabetes Center, Institute for Biometrics and Epidemiology, Düsseldorf, Germany.,German Center for Diabetes Research, Neuherberg, Germany
| | - Anna Stahl-Pehe
- German Diabetes Center, Institute for Biometrics and Epidemiology, Düsseldorf, Germany.,German Center for Diabetes Research, Neuherberg, Germany
| | - Katty Castillo
- German Diabetes Center, Institute for Biometrics and Epidemiology, Düsseldorf, Germany.,German Center for Diabetes Research, Neuherberg, Germany
| | - Silvia Selinski
- German Diabetes Center, Institute for Biometrics and Epidemiology, Düsseldorf, Germany.,German Center for Diabetes Research, Neuherberg, Germany
| | - Reinhard W Holl
- University of Ulm, Institute of Epidemiology and Medical Biometry, ZIBMT, Ulm, Germany.,German Center for Diabetes Research, Neuherberg, Germany
| | - Joachim Rosenbauer
- German Diabetes Center, Institute for Biometrics and Epidemiology, Düsseldorf, Germany.,German Center for Diabetes Research, Neuherberg, Germany
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Begum M, Chittleborough C, Pilkington R, Mittinty M, Lynch J, Penno M, Smithers L. Incidence of type 1 diabetes by socio-demographic characteristics among South Australian children: Whole-of-population study. J Paediatr Child Health 2020; 56:1952-1958. [PMID: 32932553 DOI: 10.1111/jpc.15104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 06/17/2020] [Accepted: 07/06/2020] [Indexed: 11/30/2022]
Abstract
AIM To describe and compare the incidence of type 1 diabetes (T1D) in South Australia by individual and area-level socio-economic characteristics among children aged ≤11 years. METHODS This is a whole-of-population, data linkage study (n = 231 685) conducted in South Australia, and included children born from 2002 to 2013, hospitalisation followed from 2002 to 2014. The study used de-identified, linked administrative hospitalisation, birth and perinatal data from the South Australian Early Childhood Data Project. Incidence was calculated by identifying T1D cases from T1D-related hospitalisations using International Classification of Disease, 10th Revision, Australian Modification diagnosis codes (E10, E101-E109). RESULTS Overall, 333 children aged ≤11 years (173 boys) were identified as having T1D. The T1D incidence rate was 23.0 per 100 000 person-years (95% confidence interval (CI): 20.7-25.7), with no sex difference. T1D incidence was higher among children whose mothers were Caucasian, private patients and whose parents were employed. For example, T1D incidence was 26.0 per 100 000 (95% CI: 22.8-29.5) among children with both parents employed, compared to 20.0 per 100 000 (95% CI: 12.3-30.6) among children with both parents unemployed. There was no clear gradient in the association between area-level socio-economic position and T1D, with highest incidence for the fourth quintile (26.5 per 100 000 (95% CI: 20.9-33.1)). The most advantaged area (19.4 per 100 000 (95% CI: 13.8-26.5)) had lower incidence than the most disadvantaged area (23.5 per 100 000 (95% CI: 18.9-28.9)). CONCLUSION T1D incidence rates differed depending on the measures of socio-economic characteristics. Individual-level indicators showed higher incidence among more advantaged children; however, there was no clear area-level socio-economic patterning of T1D.
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Affiliation(s)
- Mumtaz Begum
- School of Public Health, The University of Adelaide, Adelaide, South Australia, Australia.,Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | - Catherine Chittleborough
- School of Public Health, The University of Adelaide, Adelaide, South Australia, Australia.,Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | - Rhiannon Pilkington
- School of Public Health, The University of Adelaide, Adelaide, South Australia, Australia.,Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | - Murthy Mittinty
- School of Public Health, The University of Adelaide, Adelaide, South Australia, Australia.,Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | - John Lynch
- School of Public Health, The University of Adelaide, Adelaide, South Australia, Australia.,Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia.,Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Megan Penno
- School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Lisa Smithers
- School of Public Health, The University of Adelaide, Adelaide, South Australia, Australia.,Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
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Anderson SG, Shoo H, Saluja S, Anderson CD, Khan A, Livingston M, Jude EB, Lunt M, Dunn G, Heald AH. Social deprivation modifies the association between incident foot ulceration and mortality in type 1 and type 2 diabetes: a longitudinal study of a primary-care cohort. Diabetologia 2018; 61:959-967. [PMID: 29264632 PMCID: PMC6448990 DOI: 10.1007/s00125-017-4522-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 09/25/2017] [Indexed: 12/17/2022]
Abstract
AIMS/HYPOTHESIS The aim of this study was to determine whether social deprivation in the presence of diabetes is an independent predictor of developing a foot ulcer and separately of mortality. METHODS This was a primary-care-based retrospective analysis of 13,955 adults with type 1 (n = 1370) or type 2 (n = 12,585) diabetes after a median follow-up of 10.5 years. Demographic characteristics, indices of social deprivation and clinical variables were assessed at baseline. The primary outcomes were new foot ulceration (in those without a previous history of foot ulcers) and all-cause mortality. Cox proportional hazard models were used to describe the associations among foot ulceration, social deprivation and mortality. RESULTS The mean age of the population was 69.4 (range: 16-89) years. The incidence of foot ulceration was greater in individuals with type 2 (8.6%) compared with type 1 diabetes (4.8%). Occurrence was similar by sex, but increased with age and deprivation index. Individuals in the highest quintile of deprivation were 77% more likely to develop a foot ulcer compared with those in the lowest quintile (OR 1.77 [95% CI 1.45, 2.14], p < 0.0001). Overall, 2946 (21.1%) deaths were recorded. Compared with individuals without a foot ulcer, the development of a foot ulcer was associated with a higher age- and sex-adjusted mortality rate (25.9% vs 14.0%), and a 72% (HR 1.72 [95% CI 1.56, 1.90], p < 0.001) increased risk of mortality in those with type 2 diabetes. Risk of death increased by 14% per quintile of deprivation in a univariable analysis (HR 1.14 [95% CI 1.10, 1.17]). In multivariable Cox regression analyses, there was a 48% increased risk of mortality in individuals with a foot ulcer (HR 1.48 [95% CI 1.33, 1.66]) independent of the Townsend index score (HR 1.13 [95% CI 1.10, 1.17], per quintile), baseline age, sex, diabetes type, smoking status, hypertension, statin use, β-blocker use, metformin use, HbA1c levels and insulin use. CONCLUSIONS/INTERPRETATION This study confirms the high mortality rate in individuals with diabetes-related foot ulcers. In addition, socioeconomic disadvantage was found to be an independent effect modifier, contributing to an increased burden of mortality in people with diabetes who develop foot ulceration. In light of this, and as diabetes service configurations are orientated for the next 5-10 years, modelling of foot ulceration risk needs to take socioeconomic disadvantage into account.
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Affiliation(s)
- Simon G Anderson
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine, and Health, Core Technology Facility, The University of Manchester, Manchester, UK
| | - Haika Shoo
- Diabetes and Endocrine Department, East Cheshire NHS Trust, Macclesfield, UK
| | - Sushant Saluja
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine, and Health, Core Technology Facility, The University of Manchester, Manchester, UK
| | | | - Adnan Khan
- Department of Endocrinology and Diabetes, Leighton Hospital, Crewe, UK
| | - Mark Livingston
- Department of Blood Sciences, Walsall Manor Hospital, Walsall, UK
| | - Edward B Jude
- Department of Diabetes and Endocrinology, Tameside Hospital NHS Foundation Trust, Ashton-under-Lyme, UK
| | - Mark Lunt
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, School of Biological Sciences and Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - George Dunn
- Department of Podiatry, East Cheshire NHS Trust, Macclesfield, UK
| | - Adrian H Heald
- Salford Royal NHS Foundation Trust, Diabetes and Endocrinology, Stott Lane, Salford, UK.
- School of Medical Sciences, Faculty of Biology, Medicine, and Health, and Manchester Academic Health Science Centre (MAHSC), The University of Manchester, 46 Grafton Street, Manchester, M13 9NT, UK.
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Viner RM, White B, Amin R, Peters C, Khanolkar A, Christie D, Hindmarsh PC. Impact of deprivation, ethnicity, and insulin pump therapy on developmental trajectories of diabetes control in COB type 1 diabetes. Pediatr Diabetes 2017; 18:384-391. [PMID: 27534520 DOI: 10.1111/pedi.12407] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 04/18/2016] [Accepted: 05/30/2016] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND There is marked variation in diabetes outcomes for children and adolescents across the UK. We used modelling techniques to examine the independent contributions of deprivation, ethnicity, insulin pump use, and health service use on HbA1c trajectories across adolescence. METHODS Prospective data from a large UK Paediatric & Adolescent Diabetes Service on subjects with type 1 diabetes (T1D) aged 9-17 years from January 2008 to December 2013: 2560 HbA1c datapoints were available on 384 patients [193 (50.4%) female]. Sequential multilevel growth models assessed the effects of sex, duration of diabetes, deprivation, ethnicity, insulin pump use, and health service use on HbA1c . Growth mixture models were used to identify discrete HbA1c trajectories across adolescence. RESULTS Mean clinic HbA1c decreased from 2008 to 2013 by 0.122% (95% confidence interval: 0.034, 0.210; P = .007) per year. The optimal multilevel growth model showed mean HbA1c increased with age (B = 0.414, P < .0001), and that mean HbA1c was predicted by white/British ethnicity (B = -0.748, P = .004), clinic visits (B = 0.041, P = .04), and pump use (B = -0.568, P < .0001) but not deprivation. The optimal mixture model was a four trajectory group solution, with 45.1% in Good Control, 39.6% with Deteriorating Control, 6.5% with Rapidly Deteriorating Control, and 8.8% in Poor Control across adolescence. Only pump use predicted trajectory group membership, being protective against membership of all other trajectories compared with Good Control. CONCLUSIONS Increasing uptake of insulin pumps and ensuring access to health services are likely to be the most effective means of reducing inequalities in outcomes of T1D in children and young people.
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Affiliation(s)
- Russell M Viner
- UCL Institute of Child Health, London, UK.,Child & Adolescent Diabetes Service, UCL Hospitals NHS Foundation Trust, London, UK
| | - Billy White
- Child & Adolescent Diabetes Service, UCL Hospitals NHS Foundation Trust, London, UK
| | - Rakesh Amin
- UCL Institute of Child Health, London, UK.,Child & Adolescent Diabetes Service, UCL Hospitals NHS Foundation Trust, London, UK
| | - Catherine Peters
- Child & Adolescent Diabetes Service, UCL Hospitals NHS Foundation Trust, London, UK
| | | | - Deborah Christie
- Child & Adolescent Diabetes Service, UCL Hospitals NHS Foundation Trust, London, UK
| | - Peter C Hindmarsh
- UCL Institute of Child Health, London, UK.,Child & Adolescent Diabetes Service, UCL Hospitals NHS Foundation Trust, London, UK
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Watson SE, Kuhl EA, Foster MB, Omoruyi AO, Kingery SE, Woods C, Wintergerst KA. The impact of insurance coverage and the family on pediatric diabetes management. Pediatr Diabetes 2017; 18:315-319. [PMID: 27161659 DOI: 10.1111/pedi.12394] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Revised: 03/04/2016] [Accepted: 04/06/2016] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/OBJECTIVE The impact of family composition on glycemic control in children with type 1 diabetes remains unclear. We sought to evaluate the relationship between health insurance coverage, family composition, and insulin management, and assess their impact on glycemic control in a pediatric type 1 diabetes population. METHODS A retrospective chart review was completed for patients seen in the Pediatric Endocrinology Clinic at the University of Louisville in 2012. RESULTS The analysis included 729 patients with type 1 diabetes; 268 (37%) had public insurance while 461(63%) had private insurance. Compared with publicly insured patients, privately insured patients had higher rates of intensive insulin management with multiple daily injections (MDI) plans or pump devices (88 vs. 83.2%, p = 0.066) and lower HbA1c levels [8.57 vs. 9.39% (70 vs. 79 mmol/mol), p < 0.001]. Of the 729 patients, 243 were in single-adult homes (33%). Single-adult homes had higher HbA1c levels than two-adult homes, [9.3 vs. 8.6% (78 vs. 70 mmol/mol), p < 0.001]. Among publicly insured, there was no difference in HbA1c levels for single-adult vs. two-adult homes [9.4 (79 mmol/mol), p = 0.868]. For privately insured, patients in single-adult homes had higher HbA1c levels than peers in two-adult homes [9.2 vs. 8.4% (77 vs. 68), p < 0.001]. CONCLUSION Insurance type and family composition have significant associative effects on glycemic control and insulin management that may be mitigated by insulin pump therapy. Identifying and addressing factors such as availability of resources, family education, and adult support and supervision, may help improve glycemic control in high-risk pediatric diabetes patients.
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Affiliation(s)
- Sara E Watson
- Department of Pediatrics, Division of Endocrinology, University of Louisville, Louisville, KY, USA
| | - Evan A Kuhl
- Department of Pediatrics, Division of Endocrinology, University of Louisville, Louisville, KY, USA
| | - Michael B Foster
- Department of Pediatrics, Division of Endocrinology, University of Louisville, Louisville, KY, USA
| | - Adetokunbo O Omoruyi
- Department of Pediatrics, Division of Endocrinology, University of Louisville, Louisville, KY, USA
| | - Suzanne E Kingery
- Department of Pediatrics, Division of Endocrinology, University of Louisville, Louisville, KY, USA
| | - Charles Woods
- Department of Pediatrics, Division of Infectious Disease, University of Louisville, Louisville, KY, USA
| | - Kupper A Wintergerst
- Department of Pediatrics, Division of Endocrinology, University of Louisville, Louisville, KY, USA
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Khanolkar AR, Amin R, Taylor-Robinson D, Viner RM, Warner JT, Stephenson T. Young people with Type 1 diabetes of non-white ethnicity and lower socio-economic status have poorer glycaemic control in England and Wales. Diabet Med 2016; 33:1508-1515. [PMID: 26802317 DOI: 10.1111/dme.13079] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND The impact of ethnicity and socio-economic status (SES) on glycaemic control during childhood Type 1 diabetes is poorly understood in England and Wales. METHODS We studied 18 478 children with Type 1 diabetes (< 19 years) attending diabetes clinics and included in the 2012-2013 National Paediatric Diabetes Audit. Self-identified ethnicity was categorized as white, Asian, black, mixed, other and 'not-stated' (did not to divulge ethnicity). A small area measure of SES was estimated from the Index of Multiple Deprivation. Multiple linear regression was used to assess associations between ethnicity, SES and glycaemic control (mean HbA1c levels) accounting for age, gender and diabetes duration. The impact of insulin pump use on the ethnicity/SES-HbA1c associations was tested in 13 962 children. RESULTS All children from minority ethnic groups had higher mean HbA1c compared with white children, with largest differences observed in black and mixed ethnicities [8 mmol/mol (2.9%), 95% CI 5-11 and 7 mmol/mol (2.8%), 95% CI 5-9, respectively]. Lower SES was associated with higher mean HbA1c with a dose effect. The lowest SES group had a mean HbA1c that was 7 mmol/mol (2.8%) (95% CI 6-8) higher compared with the highest SES group, adjusted for ethnicity. Estimates for ethnicity were attenuated, but significant on adjustment for SES. Fewer non-white (white 20.3 vs. black 5.5%) and deprived (least deprived 21.1 vs. most deprived 13.2%) children were on insulin pump therapy. Ethnicity and SES remained significant predictors of HbA1c after accounting for insulin pump use. CONCLUSION The association between ethnicity and glycaemic control persists after adjustment for deprivation and pump use. An alternative approach to intensive insulin therapy might benefit these vulnerable children.
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Affiliation(s)
- A R Khanolkar
- Institute of Child Health, University College London (UCL), London, UK.
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - R Amin
- Institute of Child Health, University College London (UCL), London, UK
| | - D Taylor-Robinson
- Institute of Child Health, University College London (UCL), London, UK
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - R M Viner
- Institute of Child Health, University College London (UCL), London, UK
| | - J T Warner
- Department of Child Health, University Hospital of Wales, Cardiff, UK
| | - T Stephenson
- Institute of Child Health, University College London (UCL), London, UK
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Zuijdwijk CS, Cuerden M, Mahmud FH. Social determinants of health on glycemic control in pediatric type 1 diabetes. J Pediatr 2013; 162:730-5. [PMID: 23360562 DOI: 10.1016/j.jpeds.2012.12.010] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Revised: 10/29/2012] [Accepted: 12/04/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To evaluate the relationship between the social determinants of health (SDH) and glycemic control in a large pediatric type 1 diabetes (T1D) population. STUDY DESIGN Deprivation Indices (DI) were used to ascertain population-level measures of socioeconomic status, family structure, and ethnicity in patients with T1D followed at The Hospital for Sick Children August 2010-2011 (n = 854). DI quintile scores were determined for individual patients based on de-identified postal codes, and linked to mean patient A1Cs as a measure of glycemic control. We compared mean A1C between the most and least deprived DI quintiles. Associations were estimated controlling for age and sex, and repeated for insulin pump use. RESULTS The T1D population evaluated in this study was most concentrated in the least and most deprived quintiles of the Material DI. A1C levels were highest in patients with the greatest degree of deprivation (fifth vs first quintile) on the Material DI (9.2% vs 8.3%, P < .0001), Social DI (9.1% vs 8.3%, P < .0001), and Ethnic Concentration Index (8.9% vs 8.4%, P = .03). These relationships between measures of the SDH and A1C were not evident for patients on insulin pumps. On regression analysis, higher A1C was predicted by older age, female sex, not using pump therapy, and being in the most deprived quintile for Material and Social Deprivation, but not Ethnic Concentration. CONCLUSIONS Measures of the SDH comprising Material and Social Deprivation were significantly associated with suboptimal glycemic control in our pediatric T1D cohort. Use of insulin pump therapy also predicted A1C and may have a moderating effect on these relationships.
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Affiliation(s)
- Caroline S Zuijdwijk
- Division of Endocrinology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
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Hussen HI, Yang D, Cnattingius S, Moradi T. Type I diabetes among children and young adults: the role of country of birth, socioeconomic position and sex. Pediatr Diabetes 2013; 14:138-48. [PMID: 22925403 DOI: 10.1111/j.1399-5448.2012.00904.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Revised: 06/19/2012] [Accepted: 06/20/2012] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To investigate associations between country of birth, parental country of birth, and education with respect to incidence rate and time trends of type 1 diabetes mellitus (T1DM) among children and young adults. METHODS We followed a nation-wide cohort of 4 469 671 males and 4 231 680 females aged 0-30 years between 1969 and 2008. Incidence rate ratios (IRRs) with 95% confidence intervals (CIs) for T1DM were calculated using Poisson regression models. We further calculated age-standardized rates (ASRs) of T1DM, using the world population as standard. RESULTS During the study period, the ASR of T1DM increased among children younger than 15 years, but not among young adults (15-30 years). Compared with Swedish-born children, male and female immigrant children had 44 and 42% lower IRR of TIDM, respectively. Among offspring to immigrants, corresponding decreases in IRRs were 27 and 24%, respectively. Compared with children to parents with high education, male children to parents with low education had a 10% decreased IRR of T1DM, while no effect was observed among females. The IRR of T1DM increased with increasing age and calendar time of follow-up in both sexes (p-for trend <0.0001). In young adults, the IRR among immigrants decreased by 32% in males and 22% in females, while corresponding reductions in IRRs were less in offspring to immigrants. CONCLUSIONS We found a lower IRR of T1DM among offspring to immigrants, but especially among young immigrants compared with Sweden-born individuals. The findings show that environmental factors are important in the etiology of T1DM.
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Affiliation(s)
- Hozan Ismael Hussen
- Division of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Nobels väg 13, Box 210, SE-171 77, Stockholm, Sweden.
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Impact of Socio-economic Status on Utilization of Diabetes Educators and Diabetes Control: A Canadian Experience. Can J Diabetes 2012. [DOI: 10.1016/j.jcjd.2012.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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12
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Araujo MB, Mazza CS. Assessment of risk factors of poor metabolic control in type 1 diabetic children assisted in a public hospital in Argentina. Pediatr Diabetes 2008; 9:480-7. [PMID: 18761645 DOI: 10.1111/j.1399-5448.2008.00388.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To evaluate predictive risk variables of poor diabetes control that are present at the onset of the disease. SUBJECTS AND METHODS A prospective cohort study was carried out in a population of children with type 1 diabetes mellitus by means of a survey with information related to the clinical control of the patients, the sociodemographic and economic situations of their families, and the importance that the families attached to health care. The sample population had had the disease for over 2 yr, had no associated pathology, and was followed in an Argentinean hospital. RESULTS Data from 148 patients, 71 male (48%), were collected, with a mean hemoglobin A1c (HbA1c) of 9.3 +/- 1.62%. Patients with HbA1c <8.4% (25th percentile) were considered as having better metabolic control (BC), and those with HbA1c >10% (75th percentile) were considered with poorer control (PC). PC was significantly associated with the fact that the patients' biological parents did not live together (p = 0.01) and had not done the diabetic education together at debut of diabetes (p = 0.007). A linear regression model was used to analyze predictors of BC: presence of both parents during diabetes instruction (OR: 3.82), both parents lived together with the patient (OR: 2.39), and lower age of patients (OR: 0.89). Predictors of PC were unsatisfied basic food needs (OR: 4.33) and mothers' low level of education (OR: 2.13). CONCLUSIONS This study showed that socioeconomic and familial factors were strongly associated with metabolic control, and they will allow us to make an early detection of those patients who are more susceptible of having poor progression of diabetes.
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Affiliation(s)
- María B Araujo
- Nutrition Unit, Hospital Nacional de Pediatría JP Garrahan, Combate de los Pozos 1881, Ciudad Autónoma de Buenos Aires, Argentina.
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Does family cohesiveness and parental alexithymia predict glycaemic control in children and adolescents with diabetes? DIABETES & METABOLISM 2008; 34:473-81. [PMID: 18783976 DOI: 10.1016/j.diabet.2008.03.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2007] [Revised: 03/05/2008] [Accepted: 03/10/2008] [Indexed: 12/16/2022]
Abstract
AIM Several studies indicate that family functioning and parental expressiveness can influence children's glycaemic control. However, previous studies have had contradictory findings. Furthermore, no previous work has simultaneously explored the mother's and father's perception of family cohesiveness together with maternal and paternal alexithymia in relation to a child's diabetic control. In this study, we examined whether the parental perception of family cohesion and the parents' degree of alexithymia could predict their child's or adolescent's glycaemic control (severe hypoglycaemia, hospitalizations for hyperglycaemia and HbA(1c)) after adjusting for demographic variables. METHODS The study included 45 Belgian families with at least one type 1 diabetic child aged six to 18 years (25 girls and 20 boys). Parents completed demographic questionnaires about themselves and their children. Information on type 1 diabetes in their child and the family-medical history were also collected. The number of severe-hypoglycaemic events and hospitalizations for hyperglycaemia were documented for the last 12 months, as were HbA(1c) levels over the last 16 months. Finally, family cohesiveness (FACES-III) and parental alexithymia (TAS-20) were assessed. RESULTS Hierarchical regression analyses showed that the perception of family cohesion by mothers (P<0.05) was a predictor of the number of severe hypoglycaemic events in the last 12 months. Parents' demographic variables (marital and professional status, P<0.001) and maternal alexithymia (P<0.05) were found to be predictors of the number of hospitalizations for hyperglycaemia in the last 12 months. As for HbA(1c), only two parental demographic variables were significant predictors (marital and professional status, P<0.01 and P<0.05, respectively). CONCLUSION The maternal perception of family cohesiveness and maternal alexithymia predict on glycaemic control in children and adolescents with diabetes.
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Karavanaki K, Tsoka E, Karayianni C, Petrou V, Pippidou E, Brisimitzi M, Mavrikiou M, Kakleas K, Konstantopoulos I, Manoussakis M, Dacou-Voutetakis C. Prevalence of allergic symptoms among children with diabetes mellitus type 1 of different socioeconomic status. Pediatr Diabetes 2008; 9:407-16. [PMID: 18774999 DOI: 10.1111/j.1399-5448.2008.00444.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The aim of the study was to assess the possible associations between allergies and type 1 diabetes mellitus (DM1), stratified by social class. We studied 127 children with DM1 with a median age of 10.8 yr and 150 controls of comparable age and sex distribution. The parents completed questionnaires on their education and occupation and on their children's history of allergic symptoms, breast-feeding, viral infections, and measles-mumps-rubella (MMR) vaccination. Lower family's social class was more frequently encountered among the DM1 families than in the controls (OR = 0.56, 95% CI: 0.35-0.92). The occurrence of any allergic symptoms among children with DM1 (35.45%) was not significantly different from the controls (38.78%), neither in the total group (OR = 0.87, 95% CI: 0.52-1.45) nor in the stratified analysis by social class. Similar findings were observed regarding the different types of allergic symptoms. In the univariate analysis, breast-feeding, the experience of viral infections, and MMR vaccination were found to be protective of DM1 presentation in both upper and lower social classes. In the multiple logistic regression analysis, the experience of more than 2 infections/yr (OR = 0.12, 95% CI: 0.04-0.34), the origin from middle and upper social classes (OR = 0.42, 95% CI: 0.22-0.80) and breast-feeding (OR = 0.58, 95% CI: 0.31-1.07) were protective of DM1 occurrence. In children with DM1, the presence of allergic symptoms was not associated with the development of DM1. Among the environmental factors, the origin from middle or upper social classes, breast-feeding, the experience of viral infections, and MMR vaccination were found to have a protective effect on DM1 presentation.
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Affiliation(s)
- Kyriaki Karavanaki
- Diabetic Clinic, B' Pediatric Department, University of Athens, Athens, Greece.
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du Prel JB, Icks A, Grabert M, Holl RW, Giani G, Rosenbauer J. Socioeconomic conditions and type 1 diabetes in childhood in North Rhine-Westphalia, Germany. Diabetologia 2007; 50:720-8. [PMID: 17294165 DOI: 10.1007/s00125-007-0592-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2006] [Accepted: 11/23/2006] [Indexed: 01/30/2023]
Abstract
AIMS/HYPOTHESIS The aim of the study was to investigate the relationships between childhood type 1 diabetes and socioeconomic conditions, which might provide clues to the aetiology of the disease. MATERIALS AND METHODS In an ecological study, we investigated the relationships between socioeconomic conditions and the incidence of type 1 diabetes incidence among children aged 0-14 years in North Rhine-Westphalia (NRW), Germany, between 1996 and 2000 at the level of the 33 districts. Incidence data were obtained from the population-based NRW diabetes register and regional socioeconomic data from official statistics. Associations were assessed by Poisson regression models and Bayesian conditionally autoregressive regression models (CAR). RESULTS In simple Poisson regression, population density, proportion of non-German nationals in the population, measures of income, education and professional training, and deprivation scores were significantly associated with diabetes risk (p < 0.01). An increase of about one interquartile range (IQR) in population density, proportion of non-German nationals or household income was associated with a 9-12% decrease in diabetes incidence. A rise of about one IQR in income ratio, measures of education and professional training, or in deprivation score (high values correspond to high deprivation) was associated with an 8-12% incidence increase. There was a significantly 'linear' increasing incidence trend across five deprivation classes (relative risk: 1.06; 95% CI: 1.03-1.09). All associations were confirmed when overdispersion and spatial autocorrelation were accounted for in Poisson and CAR models. CONCLUSIONS/INTERPRETATIONS The results raise the possibility that the risk for type 1 diabetes is higher for children living in socially deprived and less densely populated areas. Subsequent investigations are necessary to verify the observed ecological relations at the individual level and to identify the causal factors behind the socioeconomic indicators.
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Affiliation(s)
- J-B du Prel
- German Diabetes Centre at Heinrich-Heine-University Düsseldorf, Institute of Biometrics and Epidemiology, Auf'm Hennekamp 65, 40225, Düsseldorf, Germany
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Sawka AM, Boulos P, Talib AS, Gafni A, Thabane L, Papaioannou A, Booth G, Gerstein HC. Low Socioeconomic Status and Increased Risk of Severe Hypoglycemia in Type 1 Diabetes: A Systematic Literature Review. Can J Diabetes 2007. [DOI: 10.1016/s1499-2671(07)13010-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Haynes A, Bulsara MK, Bower C, Codde JP, Jones TW, Davis EA. Independent effects of socioeconomic status and place of residence on the incidence of childhood type 1 diabetes in Western Australia. Pediatr Diabetes 2006; 7:94-100. [PMID: 16629715 DOI: 10.1111/j.1399-543x.2006.00153.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE To analyze the incidence of type 1 diabetes in 0- to 14-year olds in Western Australia, from 1985 to 2002, by region and socioeconomic status. METHODS Primary case ascertainment was from the prospective population-based Western Australian Diabetes Register, and secondary case ascertainment was from the Western Australian Hospital Morbidity Data System. The address at diagnosis was used to categorize cases into urban, rural and remote areas and into five socioeconomic groups using the Index of Relative Socioeconomic Disadvantage. Denominator data were obtained from the Australian Bureau of Statistics. Poisson regression was used to analyze the incidence rates by area and socioeconomic status. RESULTS There were a total of 1143 cases (904 urban, 190 rural and 49 remote). Case ascertainment was estimated to be 99.8% complete. The mean annual age-standardized incidence from 1985 to 2002 was 18.1 per 100,000 person years in urban (95% CI: 16.3-19.9), 14.3 per 100,000 in rural (95% CI: 11.4-7.3) and 8.0 per 100,000 in remote areas (95% CI: 5.8-10.3). The incidence was significantly higher in urban compared with rural (rate ratio 1.27, p = 0.001) and remote (rate ratio 2.28, p < 0.001) areas. The incidence increased with higher socioeconomic status. The incidence in the highest socioeconomic group was 56% greater than the lowest socioeconomic group (rate ratio 1.56, p < 0.001). These differences in incidence by socioeconomic status and region were independent of each other. CONCLUSIONS Higher socioeconomic status and residence in the urban area are independently associated with an increased risk of childhood type 1 diabetes in Western Australia.
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Affiliation(s)
- Aveni Haynes
- Department of Endocrinology & Diabetes, Princess Margaret Hospital, Perth, Western Australia, Australia
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Cardwell CR, Patterson CC, Allen M, Carson DJ. Diabetes care provision and glycaemic control in Northern Ireland: a UK regional audit. Arch Dis Child 2005; 90:468-73. [PMID: 15851427 PMCID: PMC1720387 DOI: 10.1136/adc.2004.061150] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
AIMS To assess the care received, compared to national guidelines, and to investigate factors associated with glycaemic control in children and adolescents with type 1 diabetes attending clinics in Northern Ireland. METHODS An audit of the care provided to all patients attending 11 paediatric diabetes clinics commenced in 2002. A research nurse interviewed 914 patients completing a questionnaire recording characteristics, social circumstances, and aspects of diabetes management, including the monitoring of complications and access to members of the diabetes team. Glycaemic control was measured by glycosylated haemoglobin (HbA1c), determined at a DCCT aligned central laboratory. RESULTS The average HbA1c concentration was 8.8% (SD 1.5%), with 20% of patients achieving recommended HbA1c levels of less than 7.5%. In the year prior to the audit, 76% of patients were reviewed by a diabetes specialist nurse and 42% were tested for microalbuminuria. After adjustment for confounding factors, better glycaemic control was identified, particularly in patients who had attended exactly four diabetes clinics in the previous year, were members of the patient association Diabetes UK, and lived with both natural parents. CONCLUSIONS In Northern Ireland only a minority of patients achieved recommended HbA1c levels. Furthermore, children and adolescents with diabetes were reviewed by fewer specialists and were less intensively monitored for microvascular complications than recommended. There was evidence of better control in children who were members of Diabetes UK, suggesting that parental attitude and involvement could lead to benefits.
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Affiliation(s)
- C R Cardwell
- Department of Epidemiology & Public Health, The Queen's University of Belfast, UK.
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Bråbäck L, Björ O, Nordahl G. Early determinants of first hospital admissions for asthma and acute bronchitis among Swedish children. Acta Paediatr 2003; 92:27-33. [PMID: 12650295 DOI: 10.1111/j.1651-2227.2003.tb00464.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
AIM To assess the changing impact of prenatal and perinatal factors with increasing age on first admissions for asthma and acute bronchitis. METHODS The Swedish Medical Birth Registry was linked to the National Hospital Discharge Registry for 214,276 Swedish children born in 1987 and 1988. The linkage comprised first admissions for acute bronchitis or asthma from 1987 to 1995. First admissions for gastroenteritis were included to distinguish between factors specific to asthma or bronchitis and non-specific factors related to an increased risk of hospital admission. RESULTS Admissions for asthma and acute bronchitis before 2 y of age had a close dose-response relationship with maternal smoking, low gestational age, low maternal age and older siblings. Very premature children exposed to more than 9 cigarettes a day in utero ran a 10 times higher risk of hospitalization than postmature children without exposure to maternal smoking. However, the proportion of admissions attributed to maternal smoking was only 4.7% after adjustments for significant covariates. The number of significant determinants declined in children with their first admission for asthma after 2 y of age but male gender and low educational level were independent determinants in all age groups. Older siblings were related to an increased risk of first asthma admission before 2 y of age but a slightly reduced risk of first admission after 2 y of age. CONCLUSION This study illustrates the varied epidemiology of asthma in different age groups. Maternal smoking was an important determinant for admission before 2 y of age but mainly in combination with other factors. The decline in hospital admissions in early childhood would therefore be small, even after the elimination of maternal smoking, if other significant perinatal and socioeconomic factors were unchanged.
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Affiliation(s)
- L Bråbäck
- Mid-Sweden Research and Development Centre, Sundsvall Hospital, Sundsvall, Sweden.
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