Influence of HbA1c and BMI on Lipid Trajectories in Youths and Young Adults With Type 1 Diabetes

Are Trends in Economic Modeling of Pediatric Diabetes Mellitus up to Date with the Clinical Practice Guidelines and the Latest Scientific Findings?

Background: Modeling techniques in the field of pediatrics present unique challenges beyond traditional model limitations, and sometimes difficulties in faithfully simulating the condition's evolution over time. Objective: This study aimed to identify whether economic modeling approaches in diabetes in pediatric patients align with the recommendations of clinical practice guidelines and the latest scientific evidence. Methods: A literature review was performed in March 2023 to identify modeling-based economic evaluations in diabetes in pediatric patients. Data were extracted and synthesized from eligible studies. Clinical practice guidelines for diabetes were gathered to compare their alignment with modeling strategies. Two endocrinology specialists provided insights on the latest findings in diabetes that are not yet included in the guidelines. A multidisciplinary group of experts agreed on the relevant themes to conduct the comparative analysis: parameter informing on glycemic control, diabetic ketoacidosis/hypoglycemia, C-peptide as prognostic biomarker, metabolic memory, age at diagnosis, socioeconomic status, pediatric-specific sources of risk equations, and pediatric-specific sources of utilities/disutilities. Results: Nineteen modeling-based studies (7 de novo, 12 predesigned models) and 34 guidelines were selected. Hemoglobin A1c was the main parameter to model the glycemic control; however, guidelines recommend the usage of complementary measures (eg, time in range) which are not included in economic models. Eight models included diabetic ketoacidosis (42.1%), 16 included hypoglycemia (84.2%), 2 included C-peptide (1 of those as prognostic factor) (10.5%) and 1 included legacy effect (5.3%). Neither guidelines nor models included recent findings, such as age at diagnosis or socioeconomic status, as prognostic factors. The lack of pediatric-specific sources for risk equations and utility/disutility values were additional limitations. Discussion: Economic models designed for assessing interventions in diabetes in pediatric patients should be based on pediatric-specific data and include novel adjuvant glucose-monitoring metrics and latest evidence on prognostic factors (C-peptide, legacy effect, age at diagnosis, socioeconomic status) to provide a more faithful reflection of the disease. Conclusions: Economic models represent useful tools to inform decision making. However, further research assessing the gaps is needed to enhance evidence-based health economic modeling that best represents reality.

Risk prediction of integrated traditional Chinese and western medicine for diabetes retinopathy based on optimized gradient boosting classifier model

In order to take full advantage of traditional Chinese medicine (TCM) and western medicine, combined with machine learning technology, to study the risk factors and better risk prediction model of diabetic retinopathy (DR), and provide basis for the screening and treatment of it. Through a retrospective study of DR cases in the real world, the electronic medical records of patients who met screening criteria were collected. Moreover, Recursive Feature Elimination with Cross-Validation (RFECV) was used for feature selection. Then, the prediction model was built based on Gradient Boosting Machine (GBM) and it was compared with 4 other popular machine learning techniques, including Logistic Regression (LR), K-Nearest Neighbors (KNN), Random Forest, and Support Vector Machine (SVM). The models were evaluated with accuracy, precision, recall, F1 score, and area under the curve (AUC) value as indicators. In addition, grid search was used to optimize the model. To explain the results of the model more intuitively, the Shapley Additive exPlanation (SHAP) method was used. A total of 9034 type 2 diabetes mellitus (T2DM) patients meeting the screening criteria were included in this study, including 1118 patients with DR. 19 features were selected using RFECV in the model construction. We constructed 5 commonly used models, including GBM, LR, KNN, Random Forest, and SVM. By comparing model performance, GBM has the highest accuracy (0.85) and AUC value (0.934), which is the best prediction model. We also carried out hyperparameter optimization of grid search for this model, and the model accuracy reached 0.88, and the AUC value increased to 0.958. Through SHAP analysis, it was found that TCM syndrome types, albumin, low density lipoprotein, triglyceride, total protein, glycosylated hemoglobin were closely related to the increased risk of DR. It can be concluded that TCM syndrome type is the risk factor of DR. The GBM classifier based on grid search optimization, with relevant risk factors of TCM and western medicine as variables, can better predict the risk of DR.

The role of sex on the prevalence of cardiovascular risk factors in children and adolescents with Type 1 diabetes: The SWEET international database

OBJECTIVE

To assess the prevalence of cardiovascular risk factors (CVRFs) in children and adolescents with type 1 diabetes (T1D) in the International SWEET registry and the possible role of clinical variables in modifying the risk of having single or multiple CVRFs.

STUDY DESIGN

The study is a cross-sectional study. Cut-off points for CVRFs were fixed according to International Society for Pediatric and Adolescent Diabetes (ISPAD) guidelines and WHO parameters: LDL cholesterol (LDL-C) > 100 mg/dL; Systolic Blood Pressure (BP-SDS) > 90th percentile for sex, age, and height; BMI-SDS > 2SD for sex and age. Logistic regression models were applied to evaluate variables associated with at least 1 or 2 CVRFs among registry children and adolescents.

RESULTS

29,649 individuals with T1D (6-18 years, T1D ≥ 2 years) participating in the SWEET prospective multicenter diabetes registry were included. In the cohort, 41 % had one or more CVRFs, and 10 % had two or more CVRFs. Thirty-five percent of enrolled individuals had LDL-C > 100 mg/dL, 26 % had BMI-SDS > 2SD, and 17 % had Systolic BP-SDS > 90th percentile. Females had higher frequency than males of having 1 or 2 CVRFs (45.1 % vs 37.4 %, 11.8 % vs 7.8 %; p < 0.001). Multivariable logistic regression models showed that sex (female), HbA1c category (>7.0 %), and age (>10 years) were associated with a higher chance of having at least 1 or 2 CVRFs (p < 0.001).

CONCLUSIONS

In children and adolescents with T1D, female sex, in addition to HbA1c above 7 %, and older age (>10 years) was associated with a higher risk of having at least a CVRF (LDL-C, BMI-SDS, BP) according to internationally defined cut-offs.

Tracking of serum lipids in healthy children on a year-to-year basis

OBJECTIVES

To assess the stability of lipid profiles throughout childhood and evaluate their onset and dynamic.

MATERIALS AND METHODS

Lipid markers were longitudinally measured in more than 1300 healthy children from the LIFE Child study (Germany) and categorized into normal, at-risk, or adverse. Year-to-year intra-person persistence of the categories during follow-ups was examined and Pearson's correlation coefficient was calculated.

RESULTS

We found strong positive correlations for TC, LDL-C and ApoB (r > 0.75, p < 0.001) from the age of four years. Correlations were lowest during the first two years of life. Most children with normal levels also had normal levels the following year. Children with at-risk levels showed a tendency towards normal levels at the follow-up visit. Adverse levels of TC, LDL-C, ApoB (all ages), and HDL-C (from age 15) persisted in more than half of the affected children. Age-dependent patterns of stability were most pronounced and similar for TC, LDL-C, and ApoB.

CONCLUSIONS

Normal levels of serum lipids show high stability and adverse levels stabilized in early childhood for TC, LDL, and ApoB. At-risk and adverse levels of TC, LDL-C or ApoB may warrant further or repeated diagnostic measurements with regards to preventing CVD in the long run.

Prevalence of LDL-hypercholesterolemia and other cardiovascular risk factors in young people with type 1 diabetes

BACKGROUND

Mortality and morbidity in people with Type 1 diabetes (T1D) is mainly caused by cardiovascular disease (CVD). Early treatment of cardiovascular risk factors (CVRFs) is of great importance.

OBJECTIVE

To analyze the prevalence of LDL-hypercholesterolemia and other CVRFs in youth with T1D.

METHODS

Clinical and laboratory parameters, and vascular thickness measurement were obtained in youth with T1D (age 6-18 years, T1D duration >1 year) attending a diabetes clinic. LDL-hypercholesterolemia, microalbuminuria and arterial hypertension were defined as CVRFs.

RESULTS

A total of 333 youth (48% girls; age: 13.3 years [10.3-15.5], median [interquartile range]) participated in the study. The T1D duration was 5.9 years [3.5-9.4] with HbA1c of 7.4% [6.8-8.0]. Intima media thickness (N=223) was 538.0 µm [470.0-618.0]). LDL-hypercholesterolemia was present in 30 participants (9%; 18 girls; age: 14.3 years [11.2-15.7]). None of the participants had persistent microalbuminuria, although 59 (18.3%) had elevated albumin excretion in a random urine specimen. LDL-hypercholesterolemia was associated with increased blood pressure (p<0.05), insulin requirement (p<0.05), HbA1c (p<0.05), triglyceride (p<0.001) and total cholesterol (p<0.001), and a family history of premature CVD (p<0.001), but negatively correlated with HDL cholesterol levels (p<0.05). Sex, pubertal status, duration of diabetes, type of therapy, and physical activity did not differ between participants with and without LDL- hypercholesterolemia. Arterial hypertension was present in 11 participants (3.3%; 4 girls; age: 14.1 years [11.1-16.1]).

CONCLUSION

LDL-hypercholesterolemia affected 9% of youth with T1D in this cohort and was associated with other CVRFs. A holistic therapeutic concept for these young people is essential.

The Theory of Hyperlipidemic Memory of Type 1 Diabetes

A literature search was conducted to identify publications addressing the early phases of lipid phenotypes in children and adults with either type 1 diabetes or type 2 diabetes. Medline, EMBASE, and Ovid were searched using the following search terms: clinical remission, partial remission, partial clinical remission, honeymoon phase, C-peptide, type 1 or 2 diabetes, children, pediatric type 1 or 2 diabetes, and paediatrics type 1 or 2 diabetes, adults, adult type 1 or type 2 diabetes. Partial clinical remission (PR) of type 1 diabetes (T1D) is characterized by continued endogenous production of insulin and C-peptide following the diagnosis and the introduction of exogenous insulin therapy. PR is associated with improved glycemic control and reduced prevalence of diabetes complications. The theory of hyperglycemic memory was proposed to explain this concept of improved glycemic outcomes in remitters (those who experienced PR) versus non-remitters (those who did not experience PR). However, this theory is incomplete as it does not explain the dichotomy in early lipid phenotypes in T1D based on PR status, which is an understudied area in diabetology and lipidology. To fill this knowledge gap, we propose the Theory of Hyperlipidemic Memory of T1D. This theory is premised on our 5-year research on early post-diagnostic dichotomy in lipid phenotypes between remitters and non-remitters across the lifespan. It provides a more rigorous explanation for the differences in lifelong atherosclerotic cardiovascular disease (ASCVD) risk between remitters and non-remitters. We conducted 4 clinical studies in pediatric and adult subjects with diabetes mellitus to characterize the particulars of the hyperlipidemic memory. In the first investigation, we explored the impact of the presence or absence of PR on lipid parameters in children and adolescents with T1D. In the second, we investigated whether pubertal maturation influenced our findings in T1D; and whether these findings could be replicated in healthy, non-diabetic children and adolescents. In the third, we leveraged our findings from T1D and controls to investigate the mechanisms of early lipid changes in T2D by comparing the earliest lipid phenotype of subjects with type 2 diabetes (T2D) to those of remitters, non-remitters, and controls. In the fourth, we investigated the impact of PR on the earliest lipid phenotypes in adults with T1D and compared these early lipid data to those of T2D subjects and controls. This body of work across the lifespan in children, adolescents, and adults supports the Theory of Hyperlipidemic Memory. This new theory clarifies why PR largely determines the risks for early-phase dyslipidemia, mid-term microvascular disease risk, and long-term ASCVD risk in subjects with T1D.

Overweight and obese youth with type 1 or type 2 diabetes share similar elevation in triglycerides during middle and late adolescence

BACKGROUND

Overweight and obesity have been observed in children with type 1 diabetes (T1D). This further increases their future risk of Cardiovascular Disease (CVD) as well as the development of other risk factors, such as dyslipidemia.

AIMS

To compare lipid profiles in children and adolescents with Type 1 diabetes and lean mass (T1L), Type 1 diabetes and overweight or obese (T1OW/OB), and type 2 diabetes (T2D).

METHODS

This was a cross-sectional study of 669 patients with T1D or T2D aged 2-19 years using retrospective data collected from 2003 to 2014. Included patients were categorized into lean (BMI < 85th ile and overweight or Obese (BMI ≥ 85th ile). Patients were subcategorized into three age groups: < 10 years, 10-14 years, and 15-19 years.

RESULTS

7.6% of patients had T2D. Of the patients with T1D, 58.9% were lean, 26.4% were overweight, and 14.7% were obese. Total Cholesterol (TC), Low-density lipoprotein cholesterol (LDL-C) and Non-HDL-C levels were similar across groups. In the 15-19 years group, Triglycerides (TG) levels were significantly higher in T1OW/OB and similar to T2D. High-density lipoprotein Cholesterol (HDL-C) was significantly lower in T2D. Weight status significantly correlated with TG and HDL-C levels in T1D and T2D groups.

CONCLUSIONS

T1OW/OB constitutes a significant proportion of the T1D population. Patients with obesity and T1D, especially if in their late adolescence, have an adverse lipid profile pattern that is comparable to adolescents with T2D. Based on these findings, risk for future CVD in T1OW/OB and T2D may be equivalent.

Joint 30-year HbA1c and lipid trajectories and mortality in type 1 diabetes

AIMS

Higher HbA1c has been associated with dyslipidemia in type 1 diabetes, but it is unknown whether there is heterogeneity in this association. Thus we assessed the longitudinal association between HbA1c and lipids over 30 years in a type 1 diabetes cohort and examined whether variation in such longitudinal patterns was associated with total and cause-specific mortality.

METHODS

Data were from the Pittsburgh Epidemiology of Diabetes Complications study (n = 581 with ≥2 visits, 51% male, baseline mean age 27, diabetes duration 19 years). Longitudinal associations between HbA1c and lipids were assessed in mixed models. Group-based multi-trajectory models identified simultaneous trajectories of HbA1c and lipids.

RESULTS

Longitudinal HbA1c was associated with Non-HDLc (p < 0.0001) and triglycerides (p < 0.0001), but not HDLc (men: p = 0.72, women: p = 0.76). There was heterogeneity in the HbA1c-Non-HDLc association only, with five HbA1c-Non-HDLc groups identified. One group (20%) had an unexpected combination of high HbA1c but normal Non-HDLc and had only moderately increased cardiovascular mortality (rate ratio [RR] = 2.80, 95% CI 1.31-6.00) and kidney disease mortality (RR = 2.30, 95% CI 0.97-5.50) compared to Low HbA1c-Normal Non-HDLc.

CONCLUSIONS

These results suggest there is a subgroup with type 1 diabetes who, despite poor glycemic control, has a relatively good prognosis, perhaps related to good Non-HDLc.

Association between glycaemic outcome and BMI in Danish children with type 1 diabetes in 2000-2018: a nationwide population-based study

AIM

To describe the development of HbA_1c and BMI over time in Danish children with type 1 diabetes; and to investigate the association between HbA_1c and BMI including influence of age, gender, diabetes duration, severe hypoglycaemia and treatment method.

METHODS

We used the nationwide Danish Registry of Childhood and Adolescent Diabetes, DanDiabKids, including annual registrations of all children with diabetes treated at Danish hospitals. With linear mixed-effects models and splines we analyzed the HbA_1c and BMI development over time as well as the association between HbA_1c and BMI including effects of gender, age, disease duration, hypoglycaemia and treatment method. BMI z-scores were calculated for these analyses.

RESULTS

For the period from 2000 to 2018, 6097 children with type 1 diabetes were identified from the DanDiabKids database. The median (interquartile range) HbA_1c level was 65 (57-74) mmol/mol (8.1%) and the median BMI z-score was 0.85 in girls and 0.67 in boys. A non-linear association was found between HbA_1c and BMI z-score, with the highest BMI z-score observed for HbA_1c values in the range of approximately 60-70 mmol/mol (7.6-6.8%). The association was modified by gender, age and diabetes duration. Severe hypoglycaemia and insulin pump treatment had a small positive impact on BMI z-score.

CONCLUSION

The association between HbA_1c and BMI z-score was non-linear, with the highest BMI z-score being observed for intermediate HbA_1c levels; however, specific patterns depended on gender, age and diabetes duration.

Diabetic neuropathy in children and youth: New and emerging risk factors

Pediatric neuropathy attributed to metabolic dysfunction is a well-known complication in children and youth with type 1 diabetes. Moreover, the rise of obesity and in particular of type 2 diabetes may cause an uptick in pediatric neuropathy incidence. However, despite the anticipated increase in neuropathy incidence, pathogenic insights and strategies to prevent or manage neuropathy in the setting of diabetes and obesity in children and youth remain unknown. Data from adult studies and available youth cohort studies are providing an initial understanding of potential diagnostic, management, and preventative measures in early life. This review discusses the current state of knowledge emanating from these efforts, with particular emphasis on the prevalence, clinical presentation, diagnostic approaches and considerations, and risk factors of neuropathy in type 1 and type 2 diabetes in children and youth. Also highlighted are current management strategies and recommendations for neuropathy in children and youth with diabetes. This knowledge, along with continued and sustained emphasis on identifying and eliminating modifiable risk factors, completing randomized controlled trials to assess effectiveness of strategies like weight loss and exercise, and enhancing awareness to support early detection and prevention, are pertinent to addressing the rising incidence of neuropathy associated with diabetes and obesity in children and youth.

Mechanisms and early patterns of dyslipidemia in pediatric type 1 and type 2 diabetes

Objectives The is no consensus on the early patterns of lipid-based cardiovascular disease (CVD) risk in youth with either type 1 diabetes (T1D) or type 2 diabetes (T2D). The aim was todetermine the differences in CVD risk, using lipid profiles, in children and adolescents with either T1D or T2D at the time of their first lipid assessment, after stratifying the T1D cohort into remitters and non-remitters based on their honeymoon history. Methods A cross-sectional study of 249 subjects consisting of 73 controls, 53 T2D subjects, and 123 T1D subjects stratified into remitters (n=44), and non-remitters (n=79). Partial clinical remission (PCR) was defined as insulin-dose adjusted HbA1c of ≤9. Pubertal status was determined by Tanner staging. Results After adjusting for age, sex, BMI, race, and pubertal status, T2D patients had significantly higher LDL-C compared to the controls (p=0.022), the remitters (p=0.029), but not the non-remitters (103.1 ± 5.9 mg/dL vs. 91.4 ± 4.2 mg/dL, p=0.49). Similarly, T2D patients had significantly higher non-HDL-C compared to the controls (p=0.006), the remitters (p=0.0002), but not the non-remitters (137.6 ± 7.1 mg/dL vs. 111.71 ± 5.0 mg/dL, p=0.053). Total cholesterol was also significantly higher in T2D patients compared to the controls (p=0.0005), the remitters (p=0.006) but not the non-remitters (183.5 ± 6.6 mg/dL vs. 166.2 ± 4.8 mg/dL, p=0.27). Conclusions Lack of the honeymoon phase in children and adolescents with T1D confers early and significantly increased lipid-based cardiovascular risk to these patients that is similar to the elevated cardiovascular risk seen in T2D.

Urinary Cyclophilin A and serum Cystatin C as biomarkers for diabetic nephropathy in children with type 1 diabetes

BACKGROUND

Currently, microalbuminuria is the gold standard for detection and prediction of diabetic nephropathy (DN). However, microalbuminuria appears once significant kidney damage has actually occurred.

OBJECTIVES

We investigated the diagnostic role of urinary Cyclophilin-A (uCypA), uCypA/creatinine ratio (uCypA/Cr) and serum Cystatin-C (sCysC) as biomarkers for early detection of DN in children with type 1 diabetes mellitus (T1DM) of short duration (2-5 years) before microalbuminuria emerges.

METHODS

uCypA, uCypA/Cr, and sCysC levels were assessed in three age- and sex-matched groups; microalbuminuric diabetic group (n = 31), normoalbuminuric diabetic group (n = 29), and control group (n = 30). Glomerular filtration rate was estimated (eGFR) based on both serum creatinine (eGFR-Cr) and sCysC (eGFR-CysC).

RESULTS

Significantly higher sCysC and lower eGFR-CysC were detected in both diabetic groups compared to controls and in microalbuminuric compared to normoalbuminuric group. No detected significant difference in eGFR-Cr values across the studied groups. Both uCypA and uCypA/Cr were significantly elevated in microalbuminuric compared to both normoalbuminuric and control groups with no difference between normoalbuminuric and control groups. Prediction of microalbuminuria was conducted using sCysC with area under curve up to 0.980. Combined use of sCysC and uCypA had better diagnostic value than uCypA alone.

CONCLUSION

sCysC is a promising early biomarker for DN in childhood T1DM before albuminuria detection. eGFR-CysC is superior to eGFR-Cr in evaluating renal status in childhood T1DM. uCypA and uCypA/Cr were useful tools in predicting microalbuminuria, although not regarded as diagnostic biomarkers for early-stage DN in T1DM children by the current study.

Predictive factors of non-HDL cholesterol in children and adolescents with type 1 diabetes mellitius: A cross-sectional study

AIMS

To assess predictors of non-HDL cholesterol in children and adolescents with T1DM.

METHODS

A cross-sectional study of 120 children and adolescents aged 7-16 with T1DM, but without any other chronic morbidities, at a referral outpatient clinic for the treatment of diabetes in Rio de Janeiro, Brazil. Socio-demographic, anthropometric, dietary, and clinical factors were assessed, which included measurements of serum lipids and glycated hemoglobin (HbA1c). Food intake was assessed by 24-h dietary recall. Multiple linear regression was adopted in the analysis.

RESULTS

The mean age of of the subjects was 11.74 ± 2.88 years, 53.3% were female, and the mean duration of T1DM was 6.68 ± 3.33 years. The mean energy intake from carbohydrates, proteins, and lipids was 51.98% (±9.20), 21.43% (±6.13), and 26.57% (±9.98), respectively. The energy intake from processed and ultra-processed foods represented 40.79% of total energy intake. The predictors of non-HDL cholesterol were: HbA1c (%) (p = 0.000, β = 8.5, CI: 4.8-12.1), duration of T1DM (p = 0.000, β = 2.8, CI: 1.3-4.3), and sex (p = 0.032, β = 10.1, CI: 0.9-19.4).

CONCLUSION

Glycemic control was the major modifiable predictor of non-HDL cholesterol concentrations, a significant indicator of cardiovascular risk.

Losing Track of Lipids in Children and Adolescents with Type 1 Diabetes: Towards Individualized Patient Care

AIM

To assess 1) the prevalence of children and adolescents with type 1 diabetes (T1D) changing from low-risk into borderline-high-risk lipid levels or from borderline-high-risk into high-risk lipid levels ('lose track of lipids') and 2) the power of a risk score including the determinants HbA1c, body mass index (BMI), gender, age, diabetes duration and ethnicity in predicting which patients lose track of lipids.

METHODS

651 children and adolescents with T1D were included in this longitudinal retrospective cohort study. Lipid dynamics and the impact of the risk score on losing track of lipids were evaluated. Kaplan-Meier analysis was used to estimate screening intervals.

RESULTS

31-43% percent of the patients had lost track of one or more lipids at the next lipid measurement. This happened more frequently in patients with a low-risk lipid level at start. Depending on the lipid parameter, 5% of patients with low-risk lipid levels lost track of lipids after 13-23 months. The risk score based on concomitant information on the determinants was moderately able to predict which patients would lose track of lipids on the short term.

CONCLUSIONS

A considerable number of children and adolescents with T1D loses track of lipids and does so within a 2-year screening interval. The predictive power of a risk score including age, BMI, gender, HbA1c, diabetes duration and ethnicity is only moderate. Future research should focus on another approach to the determinants used in this study or other determinants predictive of losing track of lipids on the short term.

Prevalence of dyslipidemia and factors affecting dyslipidemia in young adults with type 1 diabetes: evaluation of statin prescribing

Background There is limited information about cardiovascular complications among young adults (YA) with type 1 diabetes mellitus (T1DM) who are transitioning from pediatric to adult care. We aimed to study the prevalence and associated factors of dyslipidemia (DLD) and statin treatment in these patients. Methods We recruited 129 YA with T1DM aged 15-25 years. In a cross-sectional analysis, the prevalence of DLD (low-density lipoprotein cholesterol [LDL-C] ≥ 100 mg/dL, high-density lipoprotein cholesterol [HDL-C] <40 mg/dL [males] or <50 mg/dL [females], total cholesterol [TC] ≥200 mg/dL or triglycerides [TG] ≥150 mg/dL) was reported. Socioeconomic and clinical characteristics were compared between YA with and without DLD. We also assessed statin use among YA with DLD. Results DLD was found in 64% of YA, predominantly increased LDL-C (34.9%). Higher mean glycated hemoglobin (HbA1c) was associated with DLD (p < 0.043). Of all YA who met the criteria for statin therapy, only 42% had one prescribed. Conclusions The prevalence of DLD is high in YA with T1DM and is associated with poor glycemic control, and use of statin therapy in this high-risk population is low.

Mendelian Randomization Analysis Support Causal Associations of HbA1c with Circulating Triglyceride, Total and Low-density Lipoprotein Cholesterol in a Chinese Population

Previous observational studies supported a positive association of glycated hemoglobin A1c (HbA1c) level with serum triglyceride (TG), total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C). However, the causal relationship between HbA1c and either one of them was unclear in the East Asians. We performed a Mendelian Randomization (MR) analysis in a community-based study sample in Shanghai, China (n = 11,935). To clarify the cause-and-effect relationships of HbA1c with the four interested lipids, an Expanded HbA1c genetic risk score (GRS) with 17 HbA1c-related common variants and a Conservative score by excluding 11 variants were built and adopted as the Instrumental Variables (IVs), respectively. The Expanded HbA1c-GRS was associated with 0.19 unit increment in log-TG (P = 0.009), 0.42 mmol/L TC (P = 0.01), and 0.33 mmol/L LDL-C (P = 0.01); while the Conservative HbA1c-GRS was associated with 0.22 unit in log-TG (P = 0.03), 0.60 mmol/L TC (P = 0.01), and 0.51 mmol/L LDL-C (P = 0.007). No causal relationship was detected for HDL-C. Sensitivity analysis supported the above findings. In conclusions, MR analysis supports a causal role of increased HbA1c level in increment of circulating TG, TC, and LDL-C in a Chinese population.

Partial Clinical Remission of Type 1 Diabetes Mellitus in Children: Clinical Applications and Challenges with its Definitions

The honeymoon phase, or partial clinical remission (PCR) phase, of Type 1 diabetes mellitus (T1DM) is a transitory period that is marked by endogenous insulin production by surviving β cells following a diabetes diagnosis and the introduction of insulin therapy. It is a critical window in the course of the disease that has short and long-term implications for the patient, such as a significant reduction in the risk of long-term complications of T1DM. To promote long-term cardiovascular health in children with newly diagnosed T1DM, three key steps are necessary: the generation of a predictive model for non-remission, the adoption of a user-friendly monitoring tool for remission and non-remission, and the establishment of the magnitude of the early-phase cardiovascular disease risk in these children in objective terms through changes in lipid profile. However, only about 50% of children diagnosed with T1DM experience the honeymoon phase. Accurate and prompt detection of the honeymoon phase has been hampered by the lack of an objective and easily applicable predictive model for its detection at the time of T1DM diagnosis, the complex formulas needed to confirm and monitor PCR, and the absence of a straightforward, user-friendly tool for monitoring PCR. This literature review discusses the most up-to-date information in this field by describing an objective predictive model for non-remission, an easy tool for monitoring remission or non-remission, and objective evidence for the cardiovascular protective effect of PCR in the early phase of the disease. The goal is to present non-remission as an independent clinical entity with significantly poorer long-term prognosis than partial remission.

Partial Clinical Remission of Type 1 Diabetes Mellitus in Children: Clinical Applications and Challenges with its Definitions

The honeymoon phase, or partial clinical remission (PCR) phase, of Type 1 diabetes mellitus (T1DM) is a transitory period that is marked by endogenous insulin production by surviving 3 cells following a diabetes diagnosis and the introduction of insulin therapy. It is a critical window in the course of the disease that has short and long-term implications for the patient, such as a significant reduction in the risk of long-term complications of T1DM. To promote long-term cardiovascular health in children with newly diagnosed T1DM, three key steps are necessary: the generation of a predictive model for non-remission, the adoption of a user-friendly monitoring tool for remission and non-remission, and the establishment of the magnitude of the early-phase cardiovascular disease risk in these children in objective terms through changes in lipid profile. However, only about 50% of children diagnosed with T1DM experience the honeymoon phase. Accurate and prompt detection of the honeymoon phase has been hampered by the lack of an objective and easily applicable predictive model for its detection at the time of T1DM diagnosis, the complex formulas needed to confirm and monitor PCR, and the absence of a straightforward, user-friendly tool for monitoring PCR. This literature review discusses the most up-to-date information in this field by describing an objective predictive model for non-remission, an easy tool for monitoring remission or non-remission, and objective evidence for the cardiovascular protective effect of PCR in the early phase of the disease. The goal is to present non-remission as an independent clinical entity with significantly poorer long-term prognosis than partial remission.

Pubertal Lipid Levels Are Significantly Lower in Youth With Type 1 Diabetes Who Experienced Partial Clinical Remission

Importance

The physiologic changes in lipids during puberty in type 1 diabetes (T1D) are unclear because subjects in previous studies were not stratified by partial clinical remission status.

Aim

To determine the effect of partial clinical remission on lipid changes during puberty in youth with T1D.

Subjects and Methods

A retrospective cross-sectional study of 194 subjects consisting of 71 control subjects of age 12.9 ± 1.3 years and 123 subjects with T1D stratified into remitters (n = 44; age, 13.0 ± 0.8 years) and nonremitters (n = 79; age, 11.2 ± 0.6 years). Partial clinical remission was defined as insulin-dose adjusted HbA1c of ≤9. Pubertal status was determined by Tanner staging.

Results

Among the pubertal cohort, low-density lipoprotein cholesterol concentration was significantly higher in the nonremitters compared with remitters (91.1 ± 25.6 vs 77.2 ± 25.8 mg/dL, P = 0.018) and with normal-weight control subjects (91.1 ± 25.6 vs 70.4 ± 22.9 mg/dL, P = 0.009) but was similar between overweight/obese control subjects and nonremitters (89.7 ± 28.9 vs 91.1± 25.6 mg/dL, P = 0.81) and between normal-weight control subjects and remitters (70.4 ± 22.9 vs 77.2 ± 25.8 mg/dL, P = 0.39). Total cholesterol was also significantly higher in nonremitters compared with remitters (167.8 ± 30.5 vs 149.8 ± 32.1 mg/dL, P = 0.012) and with normal-weight control subjects (167.8 ± 30.5 vs 143.2 ± 30.1 mg/dL, P = 0.011) but was similar between nonremitters and overweight/obese control subjects (P = 0.098) and between remitters and normal-weight control subjects (P = 0.51). Non-high-density lipoprotein cholesterol was equally significantly higher in nonremitters compared with remitters (111.3 ± 30.1 vs 95.9 ± 29.1 mg/dL, P = 0.028) and normal-weight control subjects (111.3 ± 30.1 vs 86.2 ± 32.2 mg/dL, P = 0.028) but was similar between nonremitters and overweight/obese control subjects (P = 0.48) and between remitters vs normal-weight control subjects (P = 0.39).

Conclusions

Puberty-related reductions in low-density lipoprotein, total cholesterol, and non-high-density lipoprotein occur in remitters and normal-weight control subjects but not in nonremitters and overweight/obese control subjects.

Children with type 1 diabetes who experienced a honeymoon phase had significantly lower LDL cholesterol 5 years after diagnosis

Importance

Landmark studies showed that partial clinical remission in new-onset type 1 diabetes is associated with reduced prevalence of long-term complications, but early clinical indicators of this favorable outcome are poorly characterized.

Aim

To determine if there were any differences in lipid parameters, especially LDL-cholesterol, between remitters and non-remitters 4 to 5 years after the diagnosis of type 1 diabetes after controlling for hemoglobin A1c, body mass index, and pubertal status.

Subjects and methods

A longitudinal retrospective cohort study of 123 subjects of mean age 11.9 ± 2.9 years, [male 11.7 ± 2.9 years, (n = 55); female 12.0 ± 2.9 years, (n = 68), p = 0.60] with type 1 diabetes of 4–5 years duration. Anthropometric and biochemical data were collected at the 4^th or 5^th year after diagnosis in line with the American Diabetes Association recommendation to initiate screening for complications in children either at the beginning of puberty or 4–5 years after diagnosis. Puberty was defined by Tanner stages II-V. Partial clinical remission was defined by the gold-standard insulin-dose adjusted hemoglobin A1c (IDAA1c) of ≤9.

Results

There were 44 (35.8%) remitters (age 13.0 ± 2.5y; male 52.3%). Both the total cholesterol and LDL-cholesterol were significantly lower in remitters compared to non-remitters: LDL-C: 78.8 ± 28.7 mg/dL vs. 91.6 ± 26.5 mg/dL, p = 0.023; and total cholesterol: 151.5 ± 32.6 mg/dL vs. 167.0 ± 29.6 mg/dL, p = 0.015. Other lipid fractions were similar between the groups. There were no differences between the groups for glycemic control, body mass index z score, thyroid function, celiac disease occurrence, or vitamin D status. A greater number of remitters were in puberty compared to non-remitters (86.4% vs. 60.8%, p = 0.006). LDL-C concentration was similar in prepubertal remitters vs. non-remitters (p = 0.93), but was significantly lower in remitters in puberty compared to non-remitters in puberty (p = 0.018) after adjusting for age and duration of diabetes.

Conclusions

Children with type 1 diabetes who underwent a honeymoon phase had significantly lower LDL cholesterol 5 years after diagnosis. This early divergence in lipidemia may explain the dichotomy in the prevalence of long-term complication in type 1 diabetes between remitters and non-remitters. It also offers a pathway for targeted lipid monitoring in type 1 diabetes, by establishing non-remission as a non-modifiable risk factor for vascular complication in type 1 diabetes.

Modifiable Risk Factors for Cardiovascular Disease in Children with Type 1 Diabetes: Can Early Intervention Prevent Future Cardiovascular Events?

PURPOSE OF REVIEW

Patients with type 1 diabetes have increased risk for cardiovascular disease. The purpose of this review is to examine the following: i) current evidence for subclinical cardiovascular disease (CVD) in children with type 1 diabetes (T1DM) ii) known modifiable risk factors for CVD and their relationship to subclinical CVD in this population iii) studies that have addressed these risk factors in order to improve CVD outcomes in children with T1DM RECENT FINDINGS: Subclinical CVD presents in children as increased carotid intima-media thickness, increased arterial stiffness, and endothelial and myocardial dysfunction. Modifiable risk factors for CVD include hyperglycemia, hyperlipidemia, obesity, hypertension, depression, and autonomic dysfunction. Very few randomized controlled studies have been done in children with T1DM to examine how modification of these risk factors can affect their CVD. Children with T1DM have subclinical CVD and multiple modifiable risk factors for CVD. More research is needed to define how modification of these factors affects the progression of CVD.