Secular trends in growth in diabetes: are we winning?

Final height in children and adolescents with type 1 diabetes mellitus: A systematic review and meta-analysis

PURPOSE

Considering the high prevalence of type 1 diabetes mellitus (T1DM) together with the importance of improved physical growth and the significance of promoting healthcare quality among T1DM children, this meta-analysis aims to determine mean final height in this population group.

METHODS

We systematically searched PubMed, EMBASE, Web of Science, Scopus, and Cochrane databases for all studies published until May 2023 and reviewed references of published articles. Meta-analytic procedures were used to estimate the effect size (mean final height Z-score) among T1DM children in a random effects model. Significance values, weighted effect sizes, 95% CIs, and tests of homogeneity of variance were calculated. The included studies consisted of data from 3274 patients.

RESULTS

The mean final height Z-score for T1DM children was -0.201 (n = 25 studies, 95% CI: -0.389, -0.013; I2 = 97%), -0.262 in males (n = 20 studies, 95% CI: -0.539, 0.015, I2 = 97.1%), and -0.218 in females (n = 18 studies, 95% CI: -0.436, 0, I2 = 94.2%). The non-significant negative association between age at diagnosis, HbA1c levels, and final height Z-score is suggested by the findings of the univariate meta-regression.

CONCLUSION

Our findings indicated that children with T1DM have impaired linear growth and that monitoring of growth in these patient populations is an important issue in the management of T1DM. Due to a scarcity of studies providing data on the relationship between uncontrolled diabetes (increased HbA1c) and early diagnosis and final height, further investigation is warranted to determine whether there is indeed a correlation. Consequently, any conclusion regarding the association between uncontrolled diabetes (elevated HbA1c), early diagnosis of T1DM, and the increased risk of impaired linear growth or final height remains uncertain.

Komorbiditäten bei Typ-1-Diabetes im Kindes- und Jugendalter

Typ-1-Diabetes (T1D) ist eine der häufigsten Stoffwechselerkrankungen im Kindes- und Jugendalter. Komorbiditäten beim T1D können in physische und psychische unterteilt werden. Dieser Beitrag beschäftigt sich mit physischen/organspezifischen Komorbiditäten. Die Assoziation zwischen T1D und anderen Autoimmunerkrankungen ist gut bekannt. Die beiden häufigsten assoziierten Autoimmunerkrankungen bei Kindern und Jugendlichen mit T1D sind die Autoimmunthyreoiditis und die Zöliakie. Da diese oft asymptomatisch sind, sollen regelmäßige Screeninguntersuchungen auf eine assoziierte Autoimmunthyreoiditis und Zöliakie durchgeführt werden. Weitere Komorbiditäten können die Haut, das Gewicht und Längenwachstum sowie die Knochen und Gelenke betreffen. Regelmäßige Messungen von Körperlänge und -gewicht (Perzentilen), Blutdruck (Perzentilen), die Beurteilung der Pubertätsentwicklung (Tanner-Stadien) sowie die regelmäßige Überprüfung der Haut, hier v. a. die Injektions‑/Katheter- und Sensor-Stellen, sollen fixer Bestandteil der Langzeitbetreuung von Kindern und Jugendlichen mit T1D sein.

Insulin Pump Therapy

BACKGROUND

Advances in pump technology have increased the popularity of this treatment modality among patients with type 1 diabetes and recently also among patients with type 2 diabetes.

AREAS OF UNCERTAINTY

Four decades after the incorporation of the insulin pump in clinical use, questions regarding its efficacy, occurrence rate of short-term complications as hypoglycemia and diabetes ketoacidosis, timing of pump initiation, and selected populations for use remain unanswered.

DATA SOURCES

A review of the literature was performed using the PubMed database to identify all articles published up till December 2018, with the search terms including insulin pump therapy/continuous subcutaneous insulin delivery. The Cochrane database was searched for meta-analysis evaluating controlled randomized trials. Consensuses guidelines published by the International Society for Pediatric and Adolescent Diabetes, American Diabetes Association, and Advanced Technologies and Treatments for Diabetes year books were additionally reviewed for relevant cited articles.

THERAPEUTIC ADVANCES

Insulin pump therapy offers flexible management of diabetes. It enables adjustment of basal insulin to daily requirements and circadian needs, offers more precise treatment for meals and physical activity, and, when integrated with continuous glucose monitoring, allows glucose responsive insulin delivery. The ability to download and transmit data for analysis allow for treatment optimization. Newer pumps are simple to operate and increase user experience. Studies support the efficacy of pump therapy in improving glycemic control and reducing the occurrence of hypoglycemia without increasing episodes of diabetes ketoacidosis. They also improve quality of life. Recent evidence suggests a role for pump therapy in reducing microvascular and macrovascular diabetes-related complications.

CONCLUSIONS

Insulin pump therapy appears to be effective and safe in people with T1D regardless of age. Future advancements will include incorporation of closed loop and various decision support systems to aid and improve metabolic control and quality of life.

Linear Growth in Children and Adolescents with Type 1 Diabetes Mellitus

Ensuring normal linear growth is one of the major therapeutic aims in the management of type one diabetes mellitus (T1DM) in children and adolescents. Many studies in the literature have shown that pediatric patients with T1DM frequently present some abnormalities in their growth hormone (GH)/insulin-like growth factor-1 (IGF-1) axis compared to their healthy peers. Data on the growth of T1DM children and adolescents are still discordant: Some studies have reported that T1DM populations, especially those whose diabetes began in early childhood, are taller than healthy pediatric populations at diagnosis, while other studies have not found any difference. Moreover, many reports have highlighted a growth impairment in T1DM patients of prepubertal and pubertal age, and this impairment seems to be influenced by suboptimal glycemic control and disease duration. However, the most recent data showed that children treated with modern intensive insulin therapies reach a normal final adult height. This narrative review aims to provide current knowledge regarding linear growth in children and adolescents with T1DM. Currently, the choice of the most appropriate therapeutic regimen to achieve a good insulin level and the best metabolic control for each patient, together with the regular measurement of growth parameters, remains the most important available tool for a pediatric diabetologist. Nevertheless, since new technologies are the therapy of choice in young children, especially those of pre-school age, it would be of great interest to evaluate their effects on the growth pattern of children with T1DM.

The influence of treatment, age at onset, and metabolic control on height in children and adolescents with type 1 diabetes-A SWEET collaborative study

OBJECTIVE

To describe the association between height, demographics, and treatment in youths with type 1 diabetes participating in an international network for pediatric diabetes centers (SWEET).

METHODS

Data were collected from 55 centers with documented patients' height. All subjects below 20 years of age, diabetes duration >1 year, and without celiac disease were included. World Health Organization growth charts were used to calculate height and body mass index z-scores. Multiple hierarchic regression models adjusting for known confounders were applied.

RESULTS

Data on 22 941 subjects (51.8% male) were analyzed with a median and interquartile range for age 14.8 years (11.2, 17.6), diabetes duration 5.6 years (3.1, 8.9), and height z-score 0.34 (-0.37, 1.03). Children were taller in the youngest age groups: adjusted height z-scores of 0.31 (±0.06) and 0.39 (±0.06), respectively; with shorter diabetes duration (<2 years: 0.36 [±0.06]; 2-<5 years: 0.34 [±0.06]; ≥5 years: 0.21 [±0.06]) and if they were pump users: 0.35 ± 0.05 vs 0.25 ± 0.05 (>three injections/day and 0.19 ± 0.06 [0-3 injections daily]), respectively. High hemoglobin A1c (HbA1c) and low to normal weight were associated with a lower height z-score. Trends were identical in all models except for gender. No gender differences were found except in the final height model where females exhibited higher z-score than males.

CONCLUSION

For youths treated at centers offering modern diabetes management, major growth disturbances are virtually eliminated. For children with a young age at onset, high HbA1c, injections, and/or non-intensive diabetes, treatment still requires attention in order to attain normal growth.

Standard body mass index reference data of prepubescent diabetic Egyptian children

BACKGROUND

Data on the growth of diabetic children is conflicting. The aim of this study was to create and validate acceptable body mass index (BMI)-standardized percentiles and curves applied to Egyptian prepubescent diabetic children.

METHODS

The cross-sectional study comprised 822 prepubescent children with type 1 diabetes mellitus (T1DM), whose ages ranged from 3 years to 10 years±6 months. An anthropometric assessment for each child was performed: body weight, height and BMI were calculated (weight [kg]/height [m2]), and glycated hemoglobin levels were determined. Means±standard deviations (SDs) and the smoothed percentiles of the BMI from age 3-10 years, by sex, for total, controlled and uncontrolled diabetic children were calculated. Comparisons of the 50th percentiles for the controlled and uncontrolled diabetic children, by sex, with those of the Egyptian and World Health Organization (WHO) growth curves were made.

RESULTS

For controlled diabetic males and females, the 50th percentile BMI was higher than those of the Egyptian and WHO growth curves, while differences in BMI were recorded for uncontrolled diabetic males and females. For uncontrolled diabetic males, the BMI was lower than the standard Egyptian and WHO growth curves up to 5 years of age, after which it became higher than the standard WHO and lower than the standard Egyptian growth curves from 5 years up to 10 years of age. Contrary to that, the BMI of uncontrolled diabetic females was higher than the standard Egyptian and WHO growth curves up to 6.5 years, between the curves from 6.5 years up to 7.5 years and then became lower than both curves up to 10 years of age.

CONCLUSIONS

Children with T1DM should use their own BMI percentiles and never be compared with normal healthy children.

Growth in patients with type 1 diabetes

PURPOSE OF REVIEW

As the incidence of type 1 diabetes (T1DM) continues to rise, complications including impairment of childhood growth remain a major concern. This review provides an overview of alterations in growth patterns before and after the onset of T1DM.

RECENT FINDINGS

Recent advances in this field include several prospective investigations of height and weight trajectories in children leading up to the development of islet autoimmunity and T1DM as well as evaluations of larger cohorts of T1DM patients to better assess predictors of altered growth. In addition, genetic and metabolic investigations have improved our understanding of the more rare severe growth impairment of Mauriac Syndrome.

SUMMARY

Despite advances in medical care of children with T1DM, growth remains suboptimal in this population and likely reflects ongoing metabolic derangement linked with classic microvascular diabetic complications.

Why were Sardinians the shortest Europeans? A journey through genes, infections, nutrition, and sex

Since ancient times the Mediterranean island of Sardinia has been known for harboring a population with an average body height shorter than almost every other ethnic group in Europe. After over a century of investigations, the cause(s) at the origin of this uniqueness are not yet clear. The shorter stature of Sardinians appears to have been documented since prehistoric times, as revealed by the analysis of skeletal remains discovered in archaeological sites on the island. Recently, a number of genetic, hormonal, environmental, infective and nutritional factors have been put forward to explain this unique anthropometric feature, which persisted for a long time, even when environmental and living conditions improved around 1960. Although some of the putative factors are supported by sound empirical evidence, weaker support is available for others. The recent advent of whole genome analysis techniques shed new light on specific variants at the origin of this short stature. However, the marked geographical variability of stature across time and space within the island, and the well-known presence of pockets of short height in the population of the southern districts, are still puzzling findings that have attracted the interest of anthropologists and geneticists. The purpose of this review is to focus on the state-of-the-art research on stature, as well as the factors that made Sardinians the shortest among Europeans.

[Pediatric patients with type 1-diabetes: growth and growth failure associated factors]

BACKGROUND

Type 1 diabetes (T1D) usually occurs in the pediatric age and affects the growth of children. The aim of this work was to describe growth and growth failure associated factors in a population of children with T1D in a tertiary level pediatric hospital.

METHODS

A case-control nested in a cohort study was conducted. We included patients with TD1 under 16 years of age with a minimum follow-up of 12 months. Data as age at T1D diagnosis, anthropometry, glycosylated hemoglobin (HbA1c), as well as the pubertal development (Tanner stage) were collected at the time of diagnosis and during 4 years of follow-up. At the end of the follow-up, patients with growth failure and without it were compared, matched by sex, age at TD1 diagnosis. Univariate and multivariate analyses were performed.

RESULTS

On the first year of follow-up, 95 patients were gathered, 88 patients were still followed by the second year, 56 patients were kept for the third year, and 46 patients were still followed-up by the fourth year. Median age was 9.5 years and 50% were preadolescents. During their evolution, 50% had growth failure. According to the multivariate analysis, the factor associated with growth failure was the HbA1c in the first year post-diagnosis (OR 4.08; 95% CI 1.34-12.42).

CONCLUSIONS

In the first year post-diagnosis of children with T1D, HbA1c was associated with growth failure.

The Relationship between Metabolic Control and Growth in Children with Type I Diabetes Mellitus in Southwest of Iran

Background. Metabolic control is an important factor in growth of children with type I diabetes. This study assessed the relationship between growth and metabolic control in such children. Materials and Methods. 83 children with diabetes were studied. They were examined for weight and height gain and HbA1C was quantified every 3 months for one year. The growth process was studied in patients who were divided into 3 groups according to their HbA1C amounts, consisting of good, intermediate, and poor metabolic control. Results. Mean age of cases was 7.6 ± 2. The presenting sign at the onset of disease was diabetic ketoacidosis in 44.6%. The average HbA1C amount was 8.89%. The average weight SDS at diagnosis was -0.18 and at the end of the study was 0.45 (P<0.001). The average height SDS at diagnosis was -0.04 and at the end of the study was -0.07 (P=0.64). A significant difference in weight SDS changes was only seen between patients with good and poor metabolic control (P=0.04). Conclusion. Poor metabolic control can decrease height growth but has minimal influence on weight. Metabolic control was not the only predictive factor of physical growth in children with diabetes.

Physical Growth and Body Composition of Controlled Versus Uncontrolled Type 1 Egyptian Diabetic Children

BACKGROUND: Type 1 Diabetes Mellitus (T1DM) is one of the most common chronic endocrine disorders of childhood. Data on growth parameters of diabetic children is scarce.AIM: To assess growth and body composition in a group of diabetic children.SUBJECTS AND METHODS: 427 T1DM children (age 2-10 years) were recruited from Diabetic Paediatric Unit, outpatients' clinic of Abou El-Rish Hospital. Anthropometric and body composition parameters were taken and HbA1c was measured for all subjects.RESULTS:  Highly significant difference was detected between controlled and uncontrolled groups as regard to weight/age z-score, height/age z-score, BMI z-score, triceps skin fold thickness, subscapular skin fold thickness, midupper arm circumference, fat mass, fat %, lean mass, and body water (p < 0.001). All values are higher in the controlled group than in the uncontrolled group. Uncontrolled subjects were significantly more at risk of being underweight and short, with odds ratio of 15.131 and 16.877 and 95% confidence interval 1.972-116.130 and 3.973-71.694 respectively. However, controlled subjects were significantly more at risk of being obese than the uncontrolled with an odds ratio 0.116 and 95% confidence interval 0.045-0.302.CONCLUSION: Growth was compromised in uncontrolled T1DM children. This is of utmost importance since most of the clinical features are reversible with better glycemic control and appropriate insulin management.

The contribution of glycemic control to impaired growth during puberty in young people with type 1 diabetes and microalbuminuria

BACKGROUND

In adults with type 1 diabetes (T1D), short stature has been associated with risk for cardiovascular disease and nephropathy. However, there are no available data on the potential relationship between growth patterns during puberty and the development of vascular complications. Our aim was to assess whether pubertal growth is impaired in young people with T1D who develop microalbuminuria (MA).

METHODS

Repeated height measurements performed during adolescence were available for 206 young people (107 boys) with T1D followed in the Oxford Regional Prospective Study. Longitudinal data on albumin-creatinine ratios and hemoglobin A1c (HbA1c) were also collected from the study participants. Height standard deviations score (SDS) was compared between subjects with (MA+; n = 66) and without MA (MA-; n = 140).

RESULTS

In the group as a whole, mean [95% CI] height SDS progressively declined during puberty, from 0.145 [0.015; 0.274] to -0.003 [-0.145; 0.138], p < 0.001. However, the decline in height SDS was significantly different between the MA+ and MA- groups (p = 0.023), with a mean difference in final height of 4.29 [1.87; 6.72] cm, p = 0.001. Final height was inversely associated with MA (HR [95%CI]: 0.942 [0.908; 0.979], p = 0.002), although this association was no longer significant after adjusting for HbA1c, which was higher in the MA+ group.

CONCLUSION

In this study, we found a significant impairment in growth during puberty in young people with T1D, particularly in those developing MA. Poor glycemic control as well as other genetic or environmental factors could explain these associations.

[Growth and body composition of a cohort of children and adolescents with type 1 diabetes]

OBJECTIVE

To evaluate the growth and body composition of children and adolescents with type 1 diabetes mellitus (T1DM).

SUBJECTS AND METHODS

A cohort of 44 patients with T1DM were followed up for approximately four years and compared with a control group. Weight, height, body mass index (BMI), body fat percentage (BF%), fat mass index, waist circumference (WC) and waist-height ratio were determined.

RESULTS

In females, in the first evaluation, BF% was lower in patients than in controls, while in the second evaluation, mean WC was higher in patients than in controls. In males, height of the patients was lower in the first evaluation, while body mass index (BMI) was higher in the second one. We did not find any differences among the changes in height, weight and BMI z-scores and BF% or in the distribution of those z-scores between the two evaluations, in both groups. Multiple regression analysis found differences in BMI and waist-height ratio in both sexes and also in WC in females.

CONCLUSION

The patients had adequate growth but showed discrepancy in their body composition during the study.

Development and linear growth in diabetic children receiving insulin pigment

OBJECTIVE

The aim of this study was to ascertain if there are differences in the development and linear growth between a group of diabetic children who had been receiving insulin pigment and healthy children.

METHODS

A total of 57 Chinese children with type 1 diabetes diagnosed at the age from 6 to 10 years old (26 boys and 31 girls) were included in the study. Their height and weight and development conditions were recorded until they reached their 18th birthday.

RESULTS

Diabetic children were taller than healthy children at the onset of diabetes, even though there was no significant difference between them [male height standard deviation score (SDS): 0.34 +/- 0.93, female height SDS: 0.38 +/- 0.50]. When they reached their final height, they were slightly shorter than the healthy group. However, there were still no significant differences between these two groups (male height SDS: -0.42 +/- 0.95, female height SDS: -0.60 +/- 0.98). The median age at onset of puberty, 12.62 years in boys and 11.13 years in girls, was significantly delayed in diabetic boys compared to 10.55 years in healthy boys and 9.2 years in healthy girls. The median age at menarche in diabetic girls (14.15 years) was also delayed compared with 12.27 years in healthy girls. The majority of these diabetic children were thinner than the healthy children when they were diagnosed [male body mass index (BMI): 14.45 +/- 1.35 kg/m2 vs. 16.08 +/- 0.59 kg/m2, t = -0.63, p < 0.05; female BMI: 13.50 +/- 1.87 kg/m2 vs. 15.46 +/- 0.45 kg/m2, t = -6.67, p < 0.05]; however, as they reached their final height, they became fatter, especially the girls (male BMI: 21.43 +/- 1.62 kg/m2 vs. 20.8 +/- 0.00 kg/m2, t = 1.97, p > 0.05; female BMI: 23.95 +/- 2.37 kg/m2 vs. 20.3 +/- 0.00 kg/m2, t = 8.60, p < 0.05).

CONCLUSION

Even with well-controlled glucose levels, the development of children with diabetes who had been receiving insulin pigment were still adversely affected. However, linear growth had only been slightly affected. All patients, especially girls, became fatter when they reached their final height.

Growth of children with type 1 diabetes mellitus

OBJECTIVE

To retrospectively evaluate the effect of type 1 diabetes on growth.

METHODS

Patients with Type 1 diabetes mellitus (T1DM) followed for at least one year after diagnosis, and without coexisting disorder that could affect growth, were included in this retrospective analysis. Height and body mass index (BMI) values were recorded. According to the data obtained at the end of each year of disease, the patients were divided into two groups: Group 1 (patients whose height standard deviation score (SDS) did not change or showed improvement) and Group 2 (patients whose height SDS showed a decline). The two groups were compared with respect to clinical and laboratory variables.

RESULTS

Among the 248 patients followed, 101 (M/F:55/46) fulfilled the inclusion criteria. Overall, the mean height SDS of the patients did not change significantly during the follow-up period. BMI SDS showed no change during the course of the disease, except for a significant rise observed at the end of the first year compared to the value at diagnosis. Height SDS of the patients in Group 1 was higher compared to those in Group 2 from the 2nd year of disease onwards (2nd year, p=0.03; 3rd year, p=0.02; 4th year, p=0.01; 5th year, p=0.03). The ratio of patients presenting with diabetic ketoacidosis at onset was significantly higher in Group 1 at the 4th year of diagnosis (p=0.03). Additionally, the mean HbA1c level showed a modest negative correlation with Δ height SDS at the 3rd year of diagnosis (r=-0.3, p=0.03).

CONCLUSIONS

No significant deteriorative effect of T1DM on auxological parameters was observed at short term. Some clinical and laboratory variables related with metabolic control were found to correlate with growth.

[Final size attained in type 1 diabetes children]

OBJECTIVE

To describe the final height and height-gain in relation to target height, in children with type 1 diabetes mellitus, and analyse their relationship to different variables.

PATIENTS AND METHODS

Retrospective analysis of the growth data of 52 children (27 girls) diagnosed with type 1 diabetes mellitus before 14 years old, and followed up until their final height was attained.

MAIN VARIABLES

final height, target height, illness duration, glycated haemoglobin (HbA1c), insulin dose, BMI, and other autoimmune diseases.

RESULTS

The height SDS (standard deviation scale) at diagnosis was slightly higher (0.734 in boys and 0.563 in girls). During the development of the disease, a growth reduction was seen, which was significantly higher in boys of prepubertal age (p = 0.016). The mean final height attained was 173.14 +/- 5.28 cm in boys and 161.9 +/- 6.97 cm in girls. Height gain was 1.56 +/- 3.66 in boys (SDS = -0.034) and 2.26 +/- 6.13 in girls (SDS = 0.385). The only variable significantly related to height gain was mean glycated-haemoglobin (growth reduction of 2 cm for every increment of 1% in mean glycated-haemoglobin).

CONCLUSIONS

At onset, diabetic children were slightly taller than the general population. A growth reduction was shown as the disease developed, significantly higher in boys of prepubertal age. The final height in boys was slightly lower than the mean, but in girls was similar to the general population. Both sexes attained their target height, although the height gain was less in boys. Poorer metabolic control was associated with reduced height gain.

Contemporary Australian outcomes in childhood and adolescent type 1 diabetes: 10 years post the Diabetes Control and Complications Trial

The reporting of the results of the Diabetes Control and Complications Trial in 1993 has led to a major reappraisal of management practices and outcomes in type 1 diabetes in children and adolescents. A considerable body of outcome data has been generated from Australia in this post-Diabetes Control and Complications Trial era relating to incidence, metabolic control, growth, hypoglycaemia, microvascular and macrovascular complications, cognition, behaviour and quality of life. These data are important in planning future management strategies and resource allocation and as a basis for future research.

Growth, puberty, and final height in children with Type 1 diabetes

OBJECTIVE

The aims of this study were to assess the physical growth and pubertal development in a group of diabetic children and to evaluate the effect of height at diagnosis, duration of illness, and degree of glycemic control on final height and sexual maturation.

RESEARCH DESIGN

A cohort of 72 Sudanese diabetic children, 7-13 years of age at diagnosis, was followed longitudinally from the onset of diabetes until the attainment of final height.

RESULTS

The mean height standard deviation scores (SDS) at diagnosis were 0.04 in boys and -0.15 in girls, which was greater than their genetic target height (GTH). The growth velocity between diagnosis and final height was slow, with significant reduction in pubertal growth spurt. The mean final height attained by these children was lower than their GTH, a finding that contradicts most of the recently published reports. The average age at menarche in girls (15.1 years) and the mean age of full sexual maturation in boys (17.2 years) were significantly delayed in this group of diabetic patients. This retardation in physical growth and pubertal development was positively correlated with the duration of diabetes before the onset of puberty and glycated haemoglobin (HbA1c) concentration. The majority of these patients were thin at diagnosis of diabetes, with median body mass index (BMI) <22, but showed a remarkable, progressive weight gain during puberty, which was more evident in girls. The weight gain was independent of weight at diagnosis and duration of diabetes, but was positively correlated with the daily dose of insulin and HbA1c concentration.

CONCLUSION

Conventional therapy of diabetic children is associated with impairment of physical growth and delayed sexual maturation.

Insulin reverses growth hormone-induced homologous desensitization

Growth hormone (GH) is secreted in a pulsatile pattern to promote body growth and metabolism. GH exerts its function by activating several signaling pathways, including JAK2/STAT and MEK/ERK. ERK1/2 activation by GH plays important roles in gene expression, cell proliferation, and growth. We previously reported that in rat H4IIE hepatoma cells after an initial GH exposure, a second GH exposure induces STAT5 phosphorylation but not ERK1/2 phosphorylation (Ji, S., Frank, S. J., and Messina, J. L. (2002) J. Biol. Chem. 277, 28384-28393). In this study the mechanisms underlying GH-induced homologous desensitization were investigated. A second GH exposure activated the signaling intermediates upstream of MEK/ERK, including JAK2, Ras, and Raf-1. This correlated with recovery of GH receptor levels, but was insufficient for GH-induced phosphorylation of MEK1/2 and ERK1/2. Insulin restored the ability of a second GH exposure to induce phosphorylation of MEK1/2 and ERK1/2 without altering GH receptor levels or GH-induced phosphorylation/activation of JAK2 and Raf-1. GH and insulin synergized in promoting cell proliferation. Further investigation suggested that insulin increased the amount of MEK bound to KSR (kinase suppressor of Ras) and restored GH-induced tyrosine phosphorylation of KSR. Previous GH exposure also induced desensitization of STAT1 and STAT3 phosphorylation, but this desensitization was not reversed by insulin. Thus, insulin-regulated resensitization of GH signaling may be necessary to reset the complete response to GH after a normal, physiologic pulse of GH.

The role of diabetes duration, pubertal development and metabolic control in growth in children with type 1 diabetes mellitus

OBJECTIVE

To investigate whether pubertal development, duration of type 1 diabetes mellitus (DM1), or metabolic control play some role in the anomalies in growth observed in diabetic children.

PATIENTS

We conducted a prospective evaluation of 83 patients (37 female, 46 male) who were followed from the onset of DM1 at the prepubertal stage until they reached final height. All patients were treated with a conventional regimen of insulin.

METHODS

Height SDS, weight SDS, BMI SDS, duration of DM1 in years, and values of HbA1c were the study variables.

RESULTS

In prepubertal (P1) girls (data for the initial vs the intermediate evaluations): weight SDS was -0.14 +/- 0.19 vs 0.11 +/- 0.20, p = ns; BMI SDS -0.25 +/- 0.15 vs 0.01 +/- 0.13, p = ns. In postpubertal (P3) girls, weight SDS was 0.49 +/- 0.2 vs 1.2 +/- 0.32, p <0.01; BMI SDS 0.09 +/- 0.16 vs 1.03 +/- 0.24, p <0.01, whereas in P1 boys, height SDS was 0.16 +/- 0.30 vs -0.20 +/- 0.27, p <0.05; and in P3 boys: 0.09 +/- 0.21 vs -0.28 +/- 0.26, p <0.05. Thus pubertal development influenced changes observed in girls with DM1, but did not do so in boys. The anomalies described in children with DM1 were observed from the third year of DM1 duration in both girls and boys. We did not observe any correlation between HbA1c values with height SDS, weight SDS or BMI SDS.

CONCLUSIONS

The anomalies in growth observed in girls with DM1 are related to pubertal development, but this is not the case in boys. Alterations in children with DM1 were found from the third year of DM1 duration. Furthermore, the present data also indicate that the degree of metabolic control observed in our patients treated with modern but conventional regimen did not play a major role in the anomalies observed.

Insulin enhances growth hormone induction of the MEK/ERK signaling pathway

Growth hormone (GH) plays an important role in growth and metabolism by signaling via at least three major pathways, including STATs, ERK1/2, and phosphatidylinositol 3-kinase/Akt. Physiological concentrations of insulin promote growth probably by modulating liver GH receptor (GHR) levels in vivo, but the possible effects of insulin on GH-induced post-GHR signaling have yet to be studied. We hypothesized that short-term insulin, similar to the fluctuations that occur following feeding, affects GH-induced post-GHR signaling. Our present studies suggest that, in rat H4IIE hepatoma cells, insulin (4 h or less) selectively enhanced GH-induced phosphorylation of MEK1/2 and ERK1/2, but not GH-induced activation of STAT5 and Akt. Although insulin pretreatment altered GH-induced formation of Shc.Grb2.SOS complex, it did not significantly affect GH-induced activation of other signaling intermediates upstream of MEK/ERK, including JAK2, Ras, and Raf-1. Immunofluorescent staining indicated that insulin pretreatment facilitated GH-induced cell membrane translocation of MEK1/2. Insulin pretreatment also increased the amount of MEK association with its scaffolding protein, KSR. In summary, short-term insulin treatment of cultured, liver-derived cells selectively sensitized GH-induced MEK/ERK phosphorylation independent of JAK2, Ras, and Raf-1, but likely resulted from increased cell membrane translocation of MEK1/2. These findings suggest that insulin may be necessary for sensitization of cells to GH-induced ERK1/2 activation and provides a potential cellular mechanism by which insulin promotes growth.

Rates of diabetes mellitus-related complications in a contemporary adolescent cohort

BACKGROUND

Ten years after the Diabetes Control and Complications Trial there is a paucity of data as to what are current rates of diabetes-related complications in adolescence.

OBJECTIVE

To assess the incidence of diabetes-related complications in a contemporary cohort of adolescents with type 1 diabetes mellitus.

DESIGN

Retrospective cross-sectional survey.

PATIENTS

Adolescents aged >10 years with type 1 diabetes mellitus for >5 years from the Royal Children's Hospital, Melbourne Diabetes Clinic.

RESULTS

382 patients were studied (191 male). The mean HbA1c for males was 8.72% and for females was 8.80%. The rates of hypothyroidism and hypercholesterolaemia were 1.5% and 22% respectively. Twenty-five patients (8%) had intermittent microalbuminuria and six (2%) had persistent microalbuminuria. Only one patient had macroalbuminuria (0.3%). Only two patients (0.7%) with mild non-were diagnosed proliferative diabetic retinopathy. Coeliac disease was diagnosed in 6% of patients.

CONCLUSIONS

In this representative and contemporary cohort of diabetic adolescents the incidence of microvascular diabetes-related complications is quite low.

Childhood precursors of adolescent outcomes in type 1 diabetes mellitus

Contemporary outcome measures of chronic illnesses such as type 1 diabetes mellitus are broader than those clinical outcomes traditionally assessed in therapeutic encounters. A holistic approach emphasises quality of life and emotional well-being as well as the achievement of optimal disease management. This paper reviews current knowledge about growth, metabolic control, diabetes complications, neurocognitive and psychological outcomes as well as health-related quality of life in childhood diabetes mellitus. It is suggested that the antecedents of adverse diabetes and psychological outcomes in adolescence lie in the years prior to adolescence. The model of care in childhood diabetes mellitus must be focussed on earlier screening and intervention if adverse outcomes are to be reduced.

Ponderal gain, waist-to-hip ratio, and pubertal development in girls with type-1 diabetes mellitus

OBJECTIVES

We assessed pubertal development, height, weight, and waist-to-hip ratio (WHR), an index of central adiposity during puberty, in girls with type-1 diabetes mellitus (T1DM), compared to a contemporary control group.

METHODS

Pubertal development, weight, height and WHR were studied in 100 pubertal girls with T1DM, and were compared to a control group of 576 normal girls (C), recruited from schools with a similar socioeconomic level and ethnicity. The age of onset of various pubertal stages was estimated by using probit analysis.

RESULTS

Breast Tanner stage 2 (BT2) began at 8.89 +/- 0.11 and 9.10 +/- 0.28 yr in C and T1DM, respectively. A delay of 6 months was observed in T1DM for BT3 and BT4 (p < 0.05). Menarche occurred 6 months later in girls with T1DM (p = 0.03). WHR decreased during puberty in C (p < 0.001), but not in T1DM. In girls with T1DM, the body mass index standard deviation score (BMI-SDS) increased throughout puberty (p < 0.001), but it was stable in C. In T1DM girls, BMI-SDS, but not hemoglobin A1c levels (HbA1c), was a significant determinant of pubertal development. Final height was similar in T1DM and C.

CONCLUSIONS

Pubertal development in girls with T1DM occurred earlier than described in historical cohorts, but a later onset of menarche and final stages of breast development were observed. The increase in BMI-SDS and the stability of WHR in girls with T1DM during puberty suggest that this period may be critical for determining later weight gain and body composition in adult women with this condition.