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Jia Y, Long D, Yang Y, Wang Q, Wu Q, Zhang Q. Diabetic peripheral neuropathy and glycemic variability assessed by continuous glucose monitoring: A systematic review and meta-analysis. Diabetes Res Clin Pract 2024; 213:111757. [PMID: 38944250 DOI: 10.1016/j.diabres.2024.111757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 06/15/2024] [Accepted: 06/21/2024] [Indexed: 07/01/2024]
Abstract
Continuous glucose monitoring (CGM)-derived metrics have been used to accurately assess glycemic variability (GV) to facilitate management of diabetes mellitus, yet their relationship with diabetic peripheral neuropathy (DPN) is not fully understood. We performed a systematic review and meta-analysis to evaluate the association between GV metrics and the risk of developing DPN. Nine studies totaling 3,649 patients with type 1 and type 2 diabetes mellitus were included. A significant association was found between increased GV, as indicated by metrics including standard deviation (SD) with OR and 95% CI of 2.58 (1.45-4.57), mean amplitude of glycemic excursions (MAGE) with OR and 95% CI of 1.90 (1.01-3.58), mean of daily difference (MODD) with OR and 95% CI of 2.88 (2.17-3.81) and the incidence of DPN. Our findings support a link between higher GV and an increased risk of DPN in patients with diabetes. These findings highlight the potential of GV metrics as indicators for the development of DPN, advocating for their inclusion in diabetes management strategies to potentially mitigate neuropathy risk. Longitudinal studies with longer observation periods and larger sample sizes are necessary to validate these associations across diverse populations.
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Affiliation(s)
- Yifan Jia
- Department of Traditional Chinese Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Dan Long
- School of Public Health, Sun Yat-sen University, Guangzhou 510080, China
| | - Yunshuang Yang
- Department of Preventive Medicine, Beijing Longfu Hospital, Beijing 100010, China
| | - Qiong Wang
- School of Public Health, Sun Yat-sen University, Guangzhou 510080, China
| | - Qunli Wu
- Department of Traditional Chinese Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China.
| | - Qian Zhang
- Department of Traditional Chinese Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China.
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2
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ElSayed NA, Aleppo G, Bannuru RR, Bruemmer D, Collins BS, Ekhlaspour L, Hilliard ME, Johnson EL, Khunti K, Lingvay I, Matfin G, McCoy RG, Perry ML, Pilla SJ, Polsky S, Prahalad P, Pratley RE, Segal AR, Seley JJ, Stanton RC, Gabbay RA. 14. Children and Adolescents: Standards of Care in Diabetes-2024. Diabetes Care 2024; 47:S258-S281. [PMID: 38078582 PMCID: PMC10725814 DOI: 10.2337/dc24-s014] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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3
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ElSayed NA, Aleppo G, Aroda VR, Bannuru RR, Brown FM, Bruemmer D, Collins BS, Hilliard ME, Isaacs D, Johnson EL, Kahan S, Khunti K, Leon J, Lyons SK, Perry ML, Prahalad P, Pratley RE, Seley JJ, Stanton RC, Gabbay RA, on behalf of the American Diabetes Association. 14. Children and Adolescents: Standards of Care in Diabetes-2023. Diabetes Care 2023; 46:S230-S253. [PMID: 36507640 PMCID: PMC9810473 DOI: 10.2337/dc23-s014] [Citation(s) in RCA: 81] [Impact Index Per Article: 81.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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4
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Croosu SS, Røikjer J, Mørch CD, Ejskjaer N, Frøkjær JB, Hansen TM. Alterations in Functional Connectivity of Thalamus and Primary Somatosensory Cortex in Painful and Painless Diabetic Peripheral Neuropathy. Diabetes Care 2023; 46:173-182. [PMID: 36469731 DOI: 10.2337/dc22-0587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 10/13/2022] [Indexed: 12/07/2022]
Abstract
OBJECTIVE In this study we aimed to investigate the functional connectivity of brain regions involved in sensory processing in diabetes with and without painful and painless diabetic peripheral neuropathy (DPN) and the association with peripheral nerve function and pain intensity. RESEARCH DESIGN AND METHODS In this cross-sectional study we used resting-state functional MRI (fMRI) to investigate functional brain connectivity of 19 individuals with type 1 diabetes and painful DPN, 19 with type 1 diabetes and painless DPN, 18 with type 1 diabetes without DPN, and 20 healthy control subjects. Seed-based connectivity analyses were performed for thalamus, postcentral gyrus, and insula, and the connectivity z scores were correlated with peripheral nerve function measurements and pain scores. RESULTS Overall, compared with those with painful DPN and healthy control subjects, subjects with type 1 diabetes without DPN showed hyperconnectivity between thalamus and motor areas and between postcentral gyrus and motor areas (all P ≤ 0.029). Poorer peripheral nerve functions and higher pain scores were associated with lower connectivity of the thalamus and postcentral gyrus (all P ≤ 0.043). No connectivity differences were found in insula (all P ≥ 0.071). CONCLUSIONS Higher functional connectivity of thalamus and postcentral gyrus appeared only in diabetes without neuropathic complications. Thalamic/postcentral gyral connectivity measures demonstrated an association with peripheral nerve functions. Based on thalamic connectivity, it was possible to group the phenotypes of type 1 diabetes with painful/painless DPN and type 1 diabetes without DPN. The results of the current study support that fMRI can be used for phenotyping, and with validation, it may contribute to early detection and prevention of neuropathic complications.
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Affiliation(s)
- Suganthiya S Croosu
- Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Johan Røikjer
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark
- Center for Neuroplasticity and Pain, SMI, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Carsten D Mørch
- Center for Neuroplasticity and Pain, SMI, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Niels Ejskjaer
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
| | - Jens B Frøkjær
- Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Tine M Hansen
- Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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5
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Snyder LL, Foland-Ross LC, Cato A, Reiss AL, Shah C, Hossain J, Elmufti H, Nelly Mauras. Impact of dysglycemia and obesity on the brain in adolescents with and without type 2 diabetes: A pilot study. Pediatr Diabetes 2022; 23:1674-1686. [PMID: 36131363 DOI: 10.1111/pedi.13420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 08/04/2022] [Accepted: 09/17/2022] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE Both diabetes and obesity can affect the brain, yet their impact is not well characterized in children with type 2 (T2) diabetes and obesity. This pilot study aims to explore differences in brain function and cognition in adolescents with T2 diabetes and obesity and nondiabetic controls with obesity and lean controls. RESEARCH DESIGN AND METHODS Participants were 12-17 years old (5 T2 diabetes with obesity [mean HgbA1C 10.9%], 6 nondiabetic controls with obesity and 10 lean controls). Functional MRI (FMRI) during hyperglycemic/euglycemic clamps was performed in the T2 diabetes group. RESULTS When children with obesity, with and without diabetes, were grouped (mean BMI 98.8%), cognitive scores were lower than lean controls (BMI 58.4%) on verbal, full scale, and performance IQ, visual-spatial and executive function tests. Lower scores correlated with adiposity and insulin resistance but not HgbA1C. No significant brain activation differences during task based and resting state FMRI were noted between children with obesity (with or without diabetes) and lean controls, but a notable effect size for the visual-spatial working memory task and resting state was observed. CONCLUSIONS In conclusion, our pilot study suggests that obesity, insulin resistance, and dysglycemia may contribute to relatively poorer cognitive function in adolescents with T2 diabetes and obesity. Further studies with larger sample size are needed to assess if cognitive decline in children with obesity, with and without T2 diabetes, can be prevented or reversed.
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Affiliation(s)
- Lydia L Snyder
- Nemours Children's Health, Pediatric Endocrinology, Jacksonville, Florida, USA
| | - Lara C Foland-Ross
- Center for Interdisciplinary Brain Sciences Research, Stanford University, Stanford, California, USA
| | - Allison Cato
- Nemours Children's Health, Pediatric Neuropsychology, Jacksonville, Florida, USA
| | - Allan L Reiss
- Center for Interdisciplinary Brain Sciences Research, Stanford University, Stanford, California, USA
| | - Chetan Shah
- Nemours Children's Health, Pediatric Neuroradiology, Jacksonville, Florida, USA
| | - Jobayer Hossain
- Nemours Children's Health, Nemours Biomedical Research, Biostatistics Core, Wilmington, Delaware, USA
| | - Hussein Elmufti
- Nemours Children's Health, Pediatric Endocrinology, Jacksonville, Florida, USA
| | - Nelly Mauras
- Nemours Children's Health, Pediatric Endocrinology, Jacksonville, Florida, USA
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Marissal-Arvy N, Moisan MP. Diabetes and associated cognitive disorders: Role of the Hypothalamic-Pituitary Adrenal axis. Metabol Open 2022; 15:100202. [PMID: 35958117 PMCID: PMC9357829 DOI: 10.1016/j.metop.2022.100202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/18/2022] [Accepted: 07/20/2022] [Indexed: 11/12/2022] Open
Abstract
Both diabetes types, types 1 and 2, are associated with cognitive impairments. Each period of life is concerned, and this is an increasing public health problem. Animal models have been developed to investigate the biological actors involved in such impairments. Many levels of the brain function (structure, volume, neurogenesis, neurotransmission, behavior) are involved. In this review, we detailed the part potentially played by the Hypothalamic-Pituitary Adrenal axis in these dysfunctions. Notably, regulating glucocorticoid levels, their receptors and their bioavailability appear to be relevant for future research studies, and treatment development.
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Affiliation(s)
- Nathalie Marissal-Arvy
- INRAE, Laboratoire de Nutrition et Neurobiologie Intégrée, UMR 1286, UFR de Pharmacie, 146 Rue Léo Saignat, 33076, Bordeaux Cedex, France
| | - Marie-Pierre Moisan
- University of Bordeaux, Nutrition et Neurobiologie Intégrée, UMR 1286, 33000, Bordeaux, France
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7
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Reiss AL, Jo B, Arbelaez AM, Tsalikian E, Buckingham B, Weinzimer SA, Fox LA, Cato A, White NH, Tansey M, Aye T, Tamborlane W, Englert K, Lum J, Mazaika P, Foland-Ross L, Marzelli M, Mauras N. A Pilot randomized trial to examine effects of a hybrid closed-loop insulin delivery system on neurodevelopmental and cognitive outcomes in adolescents with type 1 diabetes. Nat Commun 2022; 13:4940. [PMID: 36042217 PMCID: PMC9427757 DOI: 10.1038/s41467-022-32289-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 07/26/2022] [Indexed: 12/23/2022] Open
Abstract
Type 1 diabetes (T1D) is associated with lower scores on tests of cognitive and neuropsychological function and alterations in brain structure and function in children. This proof-of-concept pilot study (ClinicalTrials.gov Identifier NCT03428932) examined whether MRI-derived indices of brain development and function and standardized IQ scores in adolescents with T1D could be improved with better diabetes control using a hybrid closed-loop insulin delivery system. Eligibility criteria for participation in the study included age between 14 and 17 years and a diagnosis of T1D before 8 years of age. Randomization to either a hybrid closed-loop or standard diabetes care group was performed after pre-qualification, consent, enrollment, and collection of medical background information. Of 46 participants assessed for eligibility, 44 met criteria and were randomized. Two randomized participants failed to complete baseline assessments and were excluded from final analyses. Participant data were collected across five academic medical centers in the United States. Research staff scoring the cognitive assessments as well as those processing imaging data were blinded to group status though participants and their families were not. Forty-two adolescents, 21 per group, underwent cognitive assessment and multi-modal brain imaging before and after the six month study duration. HbA1c and sensor glucose downloads were obtained quarterly. Primary outcomes included metrics of gray matter (total and regional volumes, cortical surface area and thickness), white matter volume, and fractional anisotropy. Estimated power to detect the predicted treatment effect was 0.83 with two-tailed, α = 0.05. Adolescents in the hybrid closed-loop group showed significantly greater improvement in several primary outcomes indicative of neurotypical development during adolescence compared to the standard care group including cortical surface area, regional gray volumes, and fractional anisotropy. The two groups were not significantly different on total gray and white matter volumes or cortical thickness. The hybrid closed loop group also showed higher Perceptual Reasoning Index IQ scores and functional brain activity more indicative of neurotypical development relative to the standard care group (both secondary outcomes). No adverse effects associated with study participation were observed. These results suggest that alterations to the developing brain in T1D might be preventable or reversible with rigorous glucose control. Long term research in this area is needed.
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Affiliation(s)
- Allan L Reiss
- Center for Interdisciplinary Brain Sciences, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA.
- Department of Radiology, Stanford University, Stanford, CA, USA.
- Department of Pediatrics, Stanford University, Stanford, CA, USA.
| | - Booil Jo
- Center for Interdisciplinary Brain Sciences, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Ana Maria Arbelaez
- Divisions of Endocrinology & Diabetes, at Washington University in St, Louis, St, Louis, MO, USA
| | - Eva Tsalikian
- Stead Family Department of Pediatrics, Endocrinology and Diabetes, University of Iowa, Iowa City, IA, USA
| | - Bruce Buckingham
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | | | - Larry A Fox
- Division of Endocrinology, Diabetes & Metabolism, Nemours Children's Health, Jacksonville, FL, USA
| | - Allison Cato
- Division of Neurology, Nemours Children's Health, Jacksonville, FL, USA
| | - Neil H White
- Divisions of Endocrinology & Diabetes, at Washington University in St, Louis, St, Louis, MO, USA
| | - Michael Tansey
- Stead Family Department of Pediatrics, Endocrinology and Diabetes, University of Iowa, Iowa City, IA, USA
| | - Tandy Aye
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | | | - Kimberly Englert
- Division of Endocrinology, Diabetes & Metabolism, Nemours Children's Health, Jacksonville, FL, USA
| | - John Lum
- Jaeb Center for Health Research, Tampa, FL, USA
| | - Paul Mazaika
- Center for Interdisciplinary Brain Sciences, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Lara Foland-Ross
- Center for Interdisciplinary Brain Sciences, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Matthew Marzelli
- Center for Interdisciplinary Brain Sciences, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Nelly Mauras
- Division of Endocrinology, Diabetes & Metabolism, Nemours Children's Health, Jacksonville, FL, USA
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Affiliation(s)
- Klemen Dovc
- UMC-University Children's Hospital Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Bruce W Bode
- Atlanta Diabetes Associates and Emory University School of Medicine, Atlanta, GA
| | - Tadej Battelino
- Atlanta Diabetes Associates and Emory University School of Medicine, Atlanta, GA
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9
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Hsu JL, Gu PS, Kang EYC, Lai CC, Lo FS. Retinal Thickness Associates with Cognition Dysfunction in Young Adult with Type 1 Diabetes in Taiwan. J Diabetes Res 2022; 2022:9082177. [PMID: 36200004 PMCID: PMC9529476 DOI: 10.1155/2022/9082177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 09/08/2022] [Accepted: 09/10/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Several factors could affect the cognitive dysfunction in patients with type 1 diabetes (T1D). OBJECTIVES To report the characteristic of cognitive dysfunction in T1D and find its association with the retinal thickness. SUBJECTS We recruited one hundred and seven patients with T1D in our study. METHODS Detailed clinical and demographic factors and Cambridge Automated Neuropsychological Test Battery (CANTAB) were performed in all participants. The age at onset>5 years old and ≤5 years old groups was defined as old- and young-onset groups. The levels of the average values of 5-year glycated hemoglobin (HbA1c_5) before study were collected. Ophthalmic study and central retinal thickness (CRT) were performed. RESULTS The median age of T1D was 24.9 years old and 57 participants were women. The median age at onset was 7.4 years old, and mean disease duration was 17.2 years. After adjusting off multiple covariates by the regression analyses, the young-onset group had significantly a longer latency in sustained attention than old-onset group (P = 0.02). The HbA1c_5 showed a significantly negative association with the sustained attention (P = 0.03). The average values of CRT showed significantly negative correlations with the reaction time in sustained attention and visual searching (P = 0.04 and P < 0.01, respectively). CONCLUSIONS Our results suggest that age at onset and glycemic control had significant impacts on different cognitive domains in T1D. The CRT had a significant correlation with sustained attention, which could be a surrogate markers of brain structural changes in T1D.
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Affiliation(s)
- Jung-Lung Hsu
- Department of Neurology, New Taipei Municipal Tucheng Hospital, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, New Taipei City, Taiwan
- Department of Neurology, Chang Gung Memorial Hospital Linkou and Neuroscience Research Center, Chang Gung University College of Medicine, Taoyuan, Taiwan
- Graduate Institute of Mind, Brain, & Consciousness, Taipei Medical University, Taipei, Taiwan
- Brain & Consciousness Research Center, Shuang Ho Hospital, New Taipei City, Taiwan
| | - Pei-Shin Gu
- Department of Pediatrics, Chang Gung Memorial Hospital Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Eugene Yu-Chuan Kang
- Department of Ophthalmology, Chang Gung Memorial Hospital Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chi-Chun Lai
- Department of Ophthalmology, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Fu-Sung Lo
- Department of Pediatrics, Chang Gung Memorial Hospital Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
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10
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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11
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Bode BW, Battelino T, Dovc K. Continuous and Intermittent Glucose Monitoring in 2020. Diabetes Technol Ther 2021; 23:S16-S31. [PMID: 34061633 DOI: 10.1089/dia.2021.2502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Bruce W Bode
- Atlanta Diabetes Associates and Emory University School of Medicine, Atlanta, GA
| | - Tadej Battelino
- UMC-University Children's Hospital Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Klemen Dovc
- UMC-University Children's Hospital Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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12
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Mauras N, Buckingham B, White NH, Tsalikian E, Weinzimer SA, Jo B, Cato A, Fox LA, Aye T, Arbelaez AM, Hershey T, Tansey M, Tamborlane W, Foland-Ross LC, Shen H, Englert K, Mazaika P, Marzelli M, Reiss AL. Impact of Type 1 Diabetes in the Developing Brain in Children: A Longitudinal Study. Diabetes Care 2021; 44:983-992. [PMID: 33568403 PMCID: PMC7985430 DOI: 10.2337/dc20-2125] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 01/05/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess whether previously observed brain and cognitive differences between children with type 1 diabetes and control subjects without diabetes persist, worsen, or improve as children grow into puberty and whether differences are associated with hyperglycemia. RESEARCH DESIGN AND METHODS One hundred forty-four children with type 1 diabetes and 72 age-matched control subjects without diabetes (mean ± SD age at baseline 7.0 ± 1.7 years, 46% female) had unsedated MRI and cognitive testing up to four times over 6.4 ± 0.4 (range 5.3-7.8) years; HbA1c and continuous glucose monitoring were done quarterly. FreeSurfer-derived brain volumes and cognitive metrics assessed longitudinally were compared between groups using mixed-effects models at 6, 8, 10, and 12 years. Correlations with glycemia were performed. RESULTS Total brain, gray, and white matter volumes and full-scale and verbal intelligence quotients (IQs) were lower in the diabetes group at 6, 8, 10, and 12 years, with estimated group differences in full-scale IQ of -4.15, -3.81, -3.46, and -3.11, respectively (P < 0.05), and total brain volume differences of -15,410, -21,159, -25,548, and -28,577 mm3 at 6, 8, 10, and 12 years, respectively (P < 0.05). Differences at baseline persisted or increased over time, and brain volumes and cognitive scores negatively correlated with a life-long HbA1c index and higher sensor glucose in diabetes. CONCLUSIONS Detectable changes in brain volumes and cognitive scores persist over time in children with early-onset type 1 diabetes followed longitudinally; these differences are associated with metrics of hyperglycemia. Whether these changes can be reversed with scrupulous diabetes control requires further study. These longitudinal data support the hypothesis that the brain is a target of diabetes complications in young children.
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Affiliation(s)
- Nelly Mauras
- Division of Endocrinology, Diabetes & Metabolism, Department of Pediatrics, Nemours Children's Health System, Jacksonville, FL
| | - Bruce Buckingham
- Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford University, Stanford, CA
| | - Neil H White
- Division of Endocrinology and Diabetes, Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Eva Tsalikian
- Division of Endocrinology and Diabetes, Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA
| | | | - Booil Jo
- Center for Interdisciplinary Brain Sciences, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA
| | - Allison Cato
- Division of Neurology, Nemours Children's Health System, Jacksonville, FL
| | - Larry A Fox
- Division of Endocrinology, Diabetes & Metabolism, Department of Pediatrics, Nemours Children's Health System, Jacksonville, FL
| | - Tandy Aye
- Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford University, Stanford, CA
| | - Ana Maria Arbelaez
- Division of Endocrinology and Diabetes, Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Tamara Hershey
- Departments of Radiology and Psychiatry, Washington University in St. Louis, St. Louis, MO
| | - Michael Tansey
- Division of Endocrinology and Diabetes, Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA
| | | | - Lara C Foland-Ross
- Center for Interdisciplinary Brain Sciences, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA
| | - Hanyang Shen
- Center for Interdisciplinary Brain Sciences, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA
| | - Kimberly Englert
- Division of Endocrinology, Diabetes & Metabolism, Department of Pediatrics, Nemours Children's Health System, Jacksonville, FL
| | - Paul Mazaika
- Center for Interdisciplinary Brain Sciences, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA
| | - Matthew Marzelli
- Center for Interdisciplinary Brain Sciences, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA
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Redondo MJ, Libman I, Maahs DM, Lyons SK, Saraco M, Reusch J, Rodriguez H, DiMeglio LA. The Evolution of Hemoglobin A 1c Targets for Youth With Type 1 Diabetes: Rationale and Supporting Evidence. Diabetes Care 2021; 44:301-312. [PMID: 33431422 PMCID: PMC7818324 DOI: 10.2337/dc20-1978] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 11/08/2020] [Indexed: 02/03/2023]
Abstract
The American Diabetes Association 2020 Standards of Medical Care in Diabetes (Standards of Care) recommends a hemoglobin A1c (A1C) of <7% (53 mmol/mol) for many children with type 1 diabetes (T1D), with an emphasis on target personalization. A higher A1C target of <7.5% may be more suitable for youth who cannot articulate symptoms of hypoglycemia or have hypoglycemia unawareness and for those who do not have access to analog insulins or advanced diabetes technologies or who cannot monitor blood glucose regularly. Even less stringent A1C targets (e.g., <8%) may be warranted for children with a history of severe hypoglycemia, severe morbidities, or short life expectancy. During the "honeymoon" period and in situations where lower mean glycemia is achievable without excessive hypoglycemia or reduced quality of life, an A1C <6.5% may be safe and effective. Here, we provide a historical perspective of A1C targets in pediatrics and highlight evidence demonstrating detrimental effects of hyperglycemia in children and adolescents, including increased likelihood of brain structure and neurocognitive abnormalities, microvascular and macrovascular complications, long-term effects, and increased mortality. We also review data supporting a decrease over time in overall severe hypoglycemia risk for youth with T1D, partly associated with the use of newer insulins and devices, and weakened association between lower A1C and severe hypoglycemia risk. We present common barriers to achieving glycemic targets in pediatric diabetes and discuss some strategies to address them. We aim to raise awareness within the community on Standards of Care updates that impact this crucial goal in pediatric diabetes management.
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Affiliation(s)
- Maria J Redondo
- Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Ingrid Libman
- Division of Pediatric Endocrinology, Diabetes and Metabolism, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - David M Maahs
- Division of Pediatric Endocrinology and Diabetes, Stanford University, Stanford, CA
- Stanford Diabetes Research Center, Stanford University, Stanford, CA
- Health Research and Policy (Epidemiology), Stanford University, Stanford, CA
| | - Sarah K Lyons
- Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | | | - Jane Reusch
- University of Colorado and Rocky Mountain Regional VA Medical Center, Aurora, CO
| | - Henry Rodriguez
- USF Diabetes and Endocrinology Section, University of South Florida, Tampa, FL
| | - Linda A DiMeglio
- Division of Pediatric Endocrinology and Diabetology and Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN
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