Ten Years of Improving Glycemic Control in Pediatric Diabetes Care: Data From the Norwegian Childhood Diabetes Registry

OBJECTIVE

To evaluate, from 2013 to 2022, how HbA1c, the incidence of acute complications, and use of diabetes technology changed at the national level in Norway and how glycemic control was associated with use of diabetes technology, carbohydrate counting, or participation in a quality improvement project.

RESEARCH DESIGN AND METHODS

This longitudinal observational study was based on 27,214 annual registrations of 6,775 children from the Norwegian Childhood Diabetes Registry from 2013 to 2022. Individuals aged >18 years, those with diabetes other than type 1, and those without HbA1c measurements were excluded. The outcome measure was HbA1c. The predictor variables in the adjusted linear mixed-effects model were 1) the use of diabetes technology, 2) the use of carbohydrate counting for meal bolusing, and 3) whether the patient's diabetes team participated in a quality improvement project.

RESULTS

Mean HbA1c decreased from 8.2% (2013) to 7.2% (2021), and the proportion of youth reaching an HbA1c <7.0% increased from 13% (2013) to 43% (2022). Insulin pump use increased from 65% (2013) to 91% (2022). Continuous glucose monitoring (CGM) use increased from 34% (first recorded in 2016) to 97% (2022). Insulin pump, CGM, and carbohydrate counting were associated with lower HbA1c and higher achievement of glycemic targets. Girls had a higher mean HbA1c than boys. Mean HbA1c levels were lower in clinics that participated in a quality improvement project for the following 4 years after the project.

CONCLUSIONS

Diabetes technology, carbohydrate counting, and systematic quality improvement in pediatric departments led to improved glycemic control.

Relation of Health-Related Quality of Life with Glycemic Control and Use of Diabetes Technology in Children and Adolescents with Type 1 Diabetes: Results from a National Population Based Study

OBJECTIVE

The primary aim was to analyse the association between diabetes-specific health-related quality of life (HRQOL) and HbA1c in children and adolescents with type 1 diabetes. The secondary aims were to evaluate the associations between diabetes-specific HRQOL and age, sex, diabetes duration, and the use of diabetes technology in diabetes treatment. Research Design and Methods. Children with type 1 diabetes (10-17 years, N = 1,019) and parents (children <10 years, N = 371; 10-17 years, N = 1,070) completed the DISABKIDS diabetes-specific questionnaire (DDM-10) as part of the 2017 data collection for the Norwegian Childhood Diabetes Registry. The DDM-10 consists of two subscales-'impact' and 'treatment'-with six and four items, respectively. In the linear regression models, the items and subscales were outcome variables, while HbA1c, age, sex, diabetes duration, insulin pump use, and continuous glucose monitoring (CGM) system use were predictor variables.

RESULTS

Lower HbA1c measurements and male sex were associated with higher HRQOL scores on both DDM-10 scales in the age group 10-17 years, but not in children under 10 years. Parents gave lower HRQOL scores than children in the 10-17 age group. Insulin pump and CGM use were not significantly associated with HRQOL on the impact and treatment scale.

CONCLUSIONS

Low HbA1c and male sex are significantly associated with high HRQOL in children aged 10-17 with type 1 diabetes, but the use of diabetes technology is not positively associated with HRQOL. Differences in child- and parent-reported scores imply that parents might both over- and underestimate their child's HRQOL.

Does Current Diabetes Technology Improve Metabolic Control? A Cross-Sectional Study on the Use of Insulin Pumps and Continuous Glucose Monitoring Devices in a Nationwide Pediatric Population

OBJECTIVE

To examine the use of multiple daily injections (MDI), insulin pumps, self-measured blood glucose (SMBG), and continuous glucose monitoring (CGM) systems, and their association with glycated hemoglobin (HbA1c), diabetic ketoacidosis (DKA), and severe hypoglycemia.

METHODS

In a pediatric population-based nationwide cross-sectional study, we analyzed data from 2623 participants up to 18 years of age with type 1 diabetes, using 2017 annual data from the Norwegian Childhood Diabetes Registry. HbA1c was adjusted for age, gender, and diabetes duration. Using a linear mixed-effects model, we assessed HbA1c and the incidence of DKA and severe hypoglycemia according to the use of MDI, insulin pumps, SMBG, and CGM.

RESULTS

We observed that 74.7% of participants were using an insulin pump and 52.6% were using a CGM system. Mean HbA1c was 7.8% (62 mmol/mol). The HbA1c of pump users was 0.14 percentage points (pp) higher than that of MDI users. Fewer pump users than MDI users achieved an HbA1c of < 7.5% (38.3 vs. 41.6%). CGM users had a 0.18 pp lower HbA1c than SMBG users, with 40.5 and 38.0%, respectively, achieving an HbA1c of < 7.5%. The incidence of severe hypoglycemia or hospitalization due to DKA was not different in pump and CGM users compared with nonusers. Compared with other insulin pumps, patch pump use was associated with a significantly lower odds ratio for DKA.

CONCLUSIONS

Despite the broad use of diabetes technology, as many as 61% of our pediatric cohort did not reach the HbA1c target recommended by the International Society for Pediatric and Adolescent Diabetes (ISPAD). Lower HbA1c was associated with CGM use but not with insulin pump use. Acute complications were not less frequent in the groups using insulin pumps or CGM compared with those using MDI and SMBG. Further research is required to explore the lower incidence of DKA among patch pump users.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT04201171.

Mental and somatic health in university students with type 1 diabetes: new results from DiaSHoT18, a cross sectional national health and well-being survey

OBJECTIVES

To explore mental and somatic health, quality of life, alcohol-related problems, sleep problems, and diabetes related distress in university students with type 1 diabetes (T1D), compared to students without T1D. Further, we evaluated associations with gender, treatment modalities, and achieved metabolic control.

METHODS

All fulltime Norwegian students aged 18-35 years pursuing higher education in 2018 (n=162.512) were invited into a comprehensive national survey on health and well-being. Students that stated having diabetes was asked further questions about their diabetes care.

RESULTS

Of 49,684 participating students, 324 participants stated having T1D. Students with T1D did not show more mental or somatic health symptoms, or report a higher level of loneliness. However, T1D was significantly associated with lower quality of life (QoL). Students with good metabolic control reached the same QoL as students without T1D. Mental disorders and suicidality were associated with lacking metabolic control. The proportion of unhealthy drinking habits was generally low, and even lower in students with T1D. Sleeping patterns were generally good, but students using continuous glucose measurement were awakening more often during sleep. Females with T1D showed higher levels of diabetes related problems and distress, but good metabolic control was associated with lower diabetes distress level.

CONCLUSIONS

Students with T1D scored equally on most mental and somatic health scales. Their quality of life was significantly worse compared to their healthy peers. Knowledge on the impact of metabolic control, gender and the use of CSII and CGM can be valuable for the caretakers of young adults with T1D.

Glycemic Outcome Associated With Insulin Pump and Glucose Sensor Use in Children and Adolescents With Type 1 Diabetes. Data From the International Pediatric Registry SWEET

OBJECTIVE

Insulin delivery methods, glucose-monitoring modalities, and related outcomes were examined in a large, international, diverse cohort of children and adolescents with type 1 diabetes from the Better Control in Pediatric and Adolescent Diabetes: Working to Create Centers of Reference (SWEET) -Registry.

RESEARCH DESIGN AND METHODS

Participants with type 1 diabetes of ≥1 year, aged ≤18 years, and who had documented pump or sensor usage during the period August 2017-July 2019 were stratified into four categories: injections-no sensor (referent); injections + sensor; pump-no sensor; and pump + sensor. HbA_1c and proportion of patients with diabetic ketoacidosis (DKA) or severe hypoglycemia (SH) were analyzed; linear and logistic regression models adjusted for demographics, region, and gross domestic product per capita were applied.

RESULTS

Data of 25,654 participants were analyzed. The proportions of participants (adjusted HbA_1c data) by study group were as follows: injections-no sensor group, 37.44% (8.72; 95% CI 8.68-8.75); injections + sensor group, 14.98% (8.30; 95% CI 8.25-8.35); pump-no sensor group, 17.22% (8.07; 95% CI 8.03-8.12); and pump + sensor group, 30.35% (7.81; 95% CI 7.77-7.84). HbA_1c was lower in all categories of participants who used a pump and/or sensor compared with the injections-no sensor treatment method (P < 0.001). The proportion of DKA episodes was lower in participants in the pump + sensor (1.98%; 95% CI 1.64-2.48; P < 0.001) and the pump-no sensor (2.02%; 95% CI 1.64-2.48; P < 0.05) groups when compared with those in the injections-no sensor group (2.91%; 95% CI 2.59-3.31). The proportion of participants experiencing SH was lower in pump-no sensor group (1.10%; 95% CI 0.85-1.43; P < 0.001) but higher in the injections + sensor group (4.25%; 95% CI 3.65-4.95; P < 0.001) compared with the injections-no sensor group (2.35%; 95% CI 2.04-2.71).

CONCLUSIONS

Lower HbA_1c and fewer DKA episodes were observed in participants using either a pump or continuous glucose monitoring (CGM) or both. Pump use was associated with a lower rate of SH. Across SWEET centers, use of pumps and CGM is increasing. The concomitant use of pump and CGM was associated with an additive benefit.

DiaSHoT18: A cross-sectional national health and well-being survey of university students with type 1 diabetes

OBJECTIVE

To achieve a better understanding in how university students live with and are able to manage their type 1 diabetes (T1D).

METHODS

In 2018, all fulltime Norwegian students aged 18 to 35 years pursuing higher education were invited into a national survey, which included data on demographics and health. In all, 162 512 students fulfilled these inclusion criteria. Students that stated having diabetes were asked to answer further questions about their diabetes care.

RESULTS

We included data from 50 054 students responding to the survey, and identified 324 students with T1D (64% females, mean age 23 years, mean HbA1c 7.65% [60 mmol/mol]). Male students had a lower HbA1c (7.28% vs 7.86%, 56 vs 62 mmol/mol), reached an HbA1c of <7.5% (58 mol/mol) more often (62.2% vs 44.2%) and were using continuous glucose measurement (CGM) less often (19.5% vs 36.7%). Exercise and smoking habits in students with T1D were equal to the non-diabetic group. More students with T1D were overweight or obese (44.1% vs 32.2%). Students who achieved an HbA1c <7.5% (58 mmol/mol) measured their blood sugar more often, had a lower body-mass index, exercised more and were smoking less. An HbA1c >7.5% (58 mmol/mol) was associated with less activity, more overweight or obesity, and smoking. The use of continuous subcutaneous insulin infusion and CGM was not associated with a better metabolic control.

CONCLUSIONS

These data have implications for the follow-up of adolescents and young adults, showing the need to focus on general lifestyle habits, especially in female subjects, whereas the use of technical devices might be of secondary importance.

A Recurrent De Novo Heterozygous COG4 Substitution Leads to Saul-Wilson Syndrome, Disrupted Vesicular Trafficking, and Altered Proteoglycan Glycosylation

The conserved oligomeric Golgi (COG) complex is involved in intracellular vesicular transport, and is composed of eight subunits distributed in two lobes, lobe A (COG1-4) and lobe B (COG5-8). We describe fourteen individuals with Saul-Wilson syndrome, a rare form of primordial dwarfism with characteristic facial and radiographic features. All affected subjects harbored heterozygous de novo variants in COG4, giving rise to the same recurrent amino acid substitution (p.Gly516Arg). Affected individuals' fibroblasts, whose COG4 mRNA and protein were not decreased, exhibited delayed anterograde vesicular trafficking from the ER to the Golgi and accelerated retrograde vesicular recycling from the Golgi to the ER. This altered steady-state equilibrium led to a decrease in Golgi volume, as well as morphologic abnormalities with collapse of the Golgi stacks. Despite these abnormalities of the Golgi apparatus, protein glycosylation in sera and fibroblasts from affected subjects was not notably altered, but decorin, a proteoglycan secreted into the extracellular matrix, showed altered Golgi-dependent glycosylation. In summary, we define a specific heterozygous COG4 substitution as the molecular basis of Saul-Wilson syndrome, a rare skeletal dysplasia distinct from biallelic COG4-CDG.

Timing of menarche in Norwegian girls: associations with body mass index, waist circumference and skinfold thickness

Background

Research studies show conflicting results regarding the association between menarche and body weight. The purpose of the present study was to investigate if anthropometric indicators of body composition, body mass index (BMI), waist circumference (WC), triceps (TSF) and subscapular skinfold (SSF) thicknesses, were differentially associated with age at menarche in Norwegian girls.

Methods

The association between menarche and BMI, WC, TSF and SSF was investigated in 1481 girls aged 8–15.5 years, and in a subgroup of 181 girls with menarche during the 12 months prior to examination. Anthropometric measures were categorized as low (< −1SDS), average (−1 ≤ SDS ≤ +1) or high (> 1SDS), and menarche according to this classification was analysed with Kaplan-Meier curves and unadjusted and adjusted Cox regression.

Results

The median age at menarche in the total sample was 13.1 years. In the unadjusted models, low categories of all traits were associated with later menarche, and high categories with earlier menarche. When adjusted for other covariates, earlier menarche was only related with a high BMI (Hazard Ratio 1.41, 95% confidence interval (CI) 1.07, 1.85), and later menarche with a low BMI (HR 0.53, 95%CI 0.38, 0.75) and low SSF (HR 0.54, 95%CI 0.39, 0.75). In girls with recent menarche, early menarche was significantly associated with a high BMI in the final model (HR 1.79, 95%CI 1.23, 2.62).

Conclusions

The timing of menarche was associated with the BMI, WC, TSF and SSF, but more strongly so with the BMI. These associations may be related to a common tempo of growth, as the mean age at menarche has remained stable during the last decades during a time period while the prevalence of overweight and obesity has increased significantly.