Comparing long-term outcomes of children treated with new-onset type 2 diabetes in an outpatient versus inpatient setting: A retrospective chart review

BACKGROUND

Early identification and management of pediatric type 2 diabetes mellitus (T2DM) is crucial for improving long-term outcomes. This study aimed to assess if the severity of T2DM at presentation, inferred by the location of treatment initiation (inpatient or outpatient), influences long-term clinical outcomes.

METHODS

A retrospective chart review was conducted on 116 pediatric T2DM patients. Data on treatment initiation location, initial and subsequent glycated hemoglobin (HbA1c) levels, prescribed insulin, and body mass index were collected from electronic medical records.

RESULTS

Of the 116 patients, 69 were initially treated in an inpatient setting, and 47 received outpatient treatment. At treatment initiation, the inpatient group had significantly higher HbA1c levels compared to the outpatient group (p < .001), but 3 years after treatment initiation, no significant difference in HbA1c was observed between the two groups (p = .057). Prescribed insulin dosages were higher in the inpatient group at treatment initiation (p < .001) and remained higher after 3 years (p < 0.003) compared to the outpatient group.

CONCLUSIONS

Pediatric patients initially treated in an inpatient setting had poorer glycemic control and higher prescribed insulin dosing at baseline. After 3 years, there was no significant difference in HbA1c levels, but patients treated as inpatients continued to have higher prescribed insulin. These findings suggest that the severity of diabetes at initial presentation may affect long-term clinical outcomes in children with T2DM.

Leptin and adiposity measures from birth to later childhood: Findings from the Hyperglycemia and Adverse Pregnancy Outcomes Follow-Up Study

BACKGROUND

Cord blood (CB) leptin is positively associated with adiposity at birth, but the association with child adiposity is unclear.

OBJECTIVES

We hypothesized that CB leptin is positively associated with adiposity in peripubertal children and with childhood leptin.

METHODS

Leptin was measured in 986 CB and 931 childhood stored samples from a prospective birth cohort. Adiposity measures were collected at birth and mean age 11.5 years. Linear and logistic regression analyses were used to evaluate associations between log-transformed CB leptin and neonatal and childhood adiposity measures as continuous and categorical variables, respectively.

RESULTS

CB leptin was positively associated with neonatal and childhood adiposity. Childhood associations were attenuated when adjusted for maternal body mass index (BMI) and glucose, but remained statistically significant for childhood body fat percentage (β = 1.15%, confidence interval [CI] = 0.46-1.84), body fat mass (β = 0.69 kg, 95% CI = 0.16-1.23), sum of skin-folds (β = 1.77 mm, 95% CI = 0.31-3.24), log-transformed child serum leptin (β = 0.13, 95% CI = 0.06-0.20), overweight/obesity (OR = 1.21, 95% CI = 1.03-1.42), obesity (OR = 1.31, 95% CI = 1.04-1.66) and body fat percentage >85th percentile (OR = 1.38, 95% CI = 1.12-1.73). Positive associations between newborn adiposity measures and CB leptin confirmed previous reports.

CONCLUSION

CB leptin is positively associated with neonatal and childhood adiposity and child leptin levels, independent of maternal BMI and maternal hyperglycemia. CB leptin may be a biomarker of future adiposity risk.

PSUN193 Comparing Long-Term Outcomes of Children Diagnosed with New-Onset Type 2 Diabetes in an Outpatient vs Inpatient Setting

Background

Early identification and treatment of children and adolescents with Type 2 Diabetes (T2DM) is thought to improve long-term outcomes. However, it is unclear if severity of T2DM at presentation affects long-term clinical outcomes. Using the location of treatment initiation (inpatient compared to outpatient) as a proxy for severity of illness, we aimed to assess changes in dysglycemia and insulin requirements at diagnosis and after 3 years of follow-up.

Methods

We performed a retrospective chart review of children 8-18 years of age diagnosed with new onset type 2 diabetes and receiving diabetes care within a large tertiary care center between 1/1/2010 and 11/1/2021 for three consecutive years. Children were identified by ICD codes (ICD9 250.00, ICD10 E13.9 or E11.9). Charts were reviewed to confirm diagnosis. Exclusion criteria included medication induced diabetes, MODY, &gt;1 positive diabetes autoantibody, BMI&lt;85%, complicated medical history (genetic disorders, transplant, cancer, etc.), and &lt; 3 visits in the study time frame. Chi-squared, t-tests, ANOVA, and linear regression were used for analyses.

Results

A total of 513 patients were identified by ICD code and, after exclusions, 116 were included in the analysis: 69 initially treated in an inpatient setting and 47 initially treated in an outpatient setting. The average A1C at presentation was higher in the inpatient group (11.02% ± 1.77) than the outpatient group (7.19% ± 0.72) (p&lt;0.001). The BMI z-score at presentation was lower in the inpatient group (2.17%±0.58) than the outpatient group (2.41% ±0.35) (p=0.015), but at three years of follow-up the BMI z-score between the groups was not significantly different (2.05%±0.60) compared to (2.12% ±0.50) (p = 0.536). The average A1C remained higher in the inpatient group (9.58%±2.92) compared to the outpatient group (8.43% ±2.44) (p = 0.031). At treatment initiation the average total daily dose of insulin in the inpatient group (0.68±0.36 units/kg/day) was higher than the outpatient group (0.05±0.18 units/kg/day) (p&lt;0.001). At three years of follow-up the average total daily dose of insulin remained higher in the inpatient group (0.50±0.46 units/kg/day) compared to the outpatient (0.29±0.36) (p=0.008 units/kg/day) group.

Conclusion

In conclusion, pediatric patients initially treated in the inpatient setting had poorer glycemic control and higher insulin requirements at baseline that persisted after three years of follow-up. These findings suggest that initial presentation may predict long-term clinical outcomes in children with T2DM.

Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

RF12 | PSUN105 Cord Blood Leptin and Childhood Adiposity Outcomes in the Hyperglycemia and Adverse Pregnancy Outcome Follow-up Study

Background/Hypothesis

Leptin is positively associated with adiposity at birth and may vary by sex. Whether cord blood leptin is associated with long term adiposity is unclear. We hypothesized that cord blood leptin is positively associated with adiposity measures in peripubertal children and that the association differs by sex.

Methods

Data from mother-child pairs in an ethnically and racially diverse prospective birth cohort were used for analysis. Leptin was measured in 990 stored cord blood samples using Millipore ELISA assays. Adiposity measures from children (mean age 11.5 ± SD 1.1 years) included body mass index (BMI), sum of three skinfolds (SSF), waist circumference (WC), and fat mass and body fat percent by air-displacement plethysmography (ADP/BOD POD). Leptin levels were log transformed to improve normality. Linear and logistic regression were used to evaluate associations between cord blood leptin and childhood adiposity outcomes for continuous and categorical variables, respectively. Statistical models accounted for covariates: Model 1 [child age, sex, field center and maternal pregnancy variables (age, parity, smoking status, drinking status, gestational age at oral glucose tolerance test (OGTT), mean arterial pressure at OGTT, family history of diabetes)] and Model 2 [Model 1+ maternal mid-pregnancy BMI + maternal gestational diabetes (present/absent)]. In Model 1, statistical interaction terms were also included to evaluate whether associations between cord blood leptin and adiposity outcomes varied by sex. Statistical significance was determined by p&lt;0.05 for all statistical tests.

Results

Cord blood leptin was positively associated with all childhood adiposity outcomes. Associations did not vary by child sex. Associations were attenuated in Model 2, but remained statistically significant. For log-cord blood leptin higher by one SD, continuous childhood adiposity outcomes were higher as follows: BMI: Model 1, beta coefficient 0.57 kg/m2 (95% CI 0.29-0.86), Model 2, 0.31 kg/m2 (95% CI 0.03-0.59); fat mass: 1.18 kg (0.66-1.71), 0.76 kg (0.23-1.29); body fat percent: 1.69% (1.02-2.36), 1.23% (0.56-1.91); SSF: 2.98 mm (1.56-4.41), 1.99 mm (0.56-3.43); and WC: 1.52 cm (0.75-2.29), 0.78 cm (0.02-1.54). For log-cord blood leptin higher by one SD, associations with dichotomous childhood adiposity outcomes were as follows: overweight/obesity: Model 1, odds ratio (OR): 1.37 (95% 1.18-1.60), Model 2, OR 1.24 (95% CI 1.06-1.45); obesity: 1.52 (1.22-1.91), 1.34 (1.06-1.70); body fat percent &gt;85th percentile: 1.49 (1.23-1.81), 1.34 (1.10-1.64); and WC &gt;85th percentile: 1.38 (1.15-1.66), 1.22 (1.01-1.48). Leptin was associated with SSF &gt;85th percentile in Model 1 1.32 (1.10-1.59) but not Model 2. Leptin was not associated with child fat-free mass.

Conclusion

Cord blood leptin is positively associated with peripubertal offspring adiposity, independent of maternal BMI and gestational diabetes. The relationship between cord blood leptin and peri-pubertal adiposity did not differ by sex.

Presentation: Saturday, June 11, 2022 1:36 p.m. - 1:41 p.m., Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Impact of SARS-CoV2 on youth onset type 2 diabetes new diagnoses and severity

INTRODUCTION

Initial reports show an increase in youth onset type 2 diabetes during the COVID-19 pandemic. We aim to expand on existing evidence by analyzing trends over a longer period.

OBJECTIVES

Our study aims to describe change in the amount, severity, and demographics of youth onset type 2 diabetes diagnoses during the COVID-19 pandemic compared to the five years before.

METHODS

We performed a retrospective cross-sectional review of youth (age ≤ 21) diagnosed with type 2 diabetes during the COVID-19 pandemic (1 May 2020-30 April 2021) and the five years before (1 May 2015-30 April 2020) at a tertiary care center. Children were identified by International Classification of Diseases codes. Charts were reviewed to confirm diagnosis. Chi-square, t tests, and Fisher's exact tests were used for analyses.

RESULTS

In the prepandemic era annual diagnoses of type 2 diabetes ranged from 41-69 (mean = 54.2), whereas during the pandemic period 159 children were diagnosed, an increase of 293%. The increase resulted in a higher incidence rate ratio during the pandemic than before, 2.77 versus 1.07 (p = .006). New diagnoses increased most, by 490%, in Non-Hispanic Black patients. The average HbA1c at presentation was higher during the pandemic (9.5% ± 2.6) (79.9 mmol/mol ± 28.2) than before (8.7%±2.1) (72.1 mmol/mol ± 23.1) (p = .003). Of those diagnosed during the pandemic, 59% were tested for COVID-19 and three tested positive.

CONCLUSIONS

New diagnoses of type 2 diabetes increased during the pandemic, most notably in Non-Hispanic Black youth. There was not a significant correlation found with clinical or biochemical COVID-19 infection in those tested.

A Mini-Review of Pediatric Anthropometrics as Predictors of Future Insulin Resistance

The impact of rising rates of childhood obesity is far reaching. Metabolic syndrome in children is increasing, yet for most children the consequences of excess adiposity will manifest in adulthood. Excess early fat accrual is a risk factor for future insulin resistance. However, certain types of fat and patterns of fat distribution are more relevant than others to metabolic risk. Therefore, adiposity measures are important. The link between childhood obesity and future insulin resistance was initially established with body mass index (BMI), but BMI is an in imperfect measure of adiposity. It is worthwhile to evaluate other anthropometrics as they may more accurately capture metabolic risk. While measures such as waist to height ratio are established as superior screening measures in adulthood - the findings are not as robust in pediatrics. Emerging evidence suggests that alternative anthropometrics may be slightly superior to BMI in identifying those youth most at risk of developing insulin resistance, but the clinical significance of that superiority appears limited. Increasing study is needed in longitudinal and varied cohorts to identify which pediatric anthropometric best predicts adult insulin resistance. We review alternative anthropometrics as predictors of future insulin resistance and identify current gaps in knowledge and potential future directions of inquiry.

Hyperparathyroidism and parathyroidectomy in X-linked hypophosphatemia patients

BACKGROUND

X-linked hypophosphatemia (XLH) causes rickets, osteomalacia, skeletal deformities and growth impairment, due to elevated fibroblast growth factor 23 and hypophosphatemia. Conventional therapy requires high doses of phosphate salts combined with active vitamin D analogues. Risks of this regimen include nephrocalcinosis and secondary hyperparathyroidism or progression to tertiary (hypercalcemic) hyperparathyroidism.

METHODS

The primary goals were to estimate the prevalence of hyperparathyroidism and to characterize parathyroidectomy outcomes regarding hypercalcemia among XLH patients. XLH patients attending our center from 1/2000 to 12/2017 were included in a retrospective chart review. Prevalence of nephrocalcinosis and eGFR < 60 ml/min/1.73m2 was also assessed.

RESULTS

Of 104 patients with XLH, 84 had concurrent measurements of calcium and PTH (40 adults and 44 children). Of these, 70/84 (83.3%), had secondary or tertiary hyperparathyroidism at any time point. Secondary hyperparathyroidism was persistent in 62.2% of those with data at multiple timepoints. Tertiary hyperparathyroidism had an overall prevalence of 14/84 (16.7%) patients. Parathyroidectomy was performed in 8/84 (9.5%) of the total population. After parathyroidectomy, persistent or recurrent tertiary hyperparathyroidism was detected in 6/8 (75%) patients at a median of 6 years (from 0 to 29 years). One patient had chronic post-surgical hypoparathyroidism and one patient remained normocalcemic 4 years after surgery. Nephrocalcinosis was more prevalent in patients with tertiary hyperparathyroidism than those without (60.0% vs 18.6%). Chronic kidney disease (eGFR < 60 ml/min/1.73m2) was also more prevalent in patients with tertiary hyperparathyroidism than those without (35.7% vs 1.5%).

CONCLUSION

The majority of patients with XLH develop secondary hyperparathyroidism during treatment with phosphate and active vitamin D. A significant proportion develops tertiary hyperparathyroidism and most have recurrence or persistence of hypercalcemia after surgery.

SUN-526 Prevalence of Hyperparathyroidism in X-Linked Hypophosphatemia

X-linked hypophosphatemia, due to PHEX mutations results in elevated fibroblast growth factor 23, hypophosphatemia and rickets/osteomalacia. Conventional therapy requires high doses of phosphate salts combined with active vitamin D analogues. Known complications of this regimen include nephrocalcinosis and secondary and tertiary hyperparathyroidism. The prevalence of hyperparathyroidism and treatment with parathyroidectomy in XLH is uncertain. The goal of this study was to estimate the prevalence of hyperparathyroidism and parathyroidectomy among XLH patients. We also characterized the outcome of parathyroidectomy for XLH patients. We conducted a retrospective chart review study from 1/1/2010 to 12/31/2017 using data from electronic records and paper charts. All XLH patients attending our center were eligible for analysis if they had at least one concurrent measurement of parathyroid hormone (PTH) and serum calcium. Categorization was based on the highest PTH and calcium values, persistence of hypercalcemia and a history of parathyroidectomy. Of the 104 patients having a diagnosis of XLH, 84 had concurrent measurements available of calcium and PTH. Data were available from 46 patients as adults and 43 as children (5 as both). Of these, 71/84 (84.52%), had evidence of secondary or tertiary hyperparathyroidism at any time point. Secondary hyperparathyroidism (defined as any PTH value ≥65pg/mL and not hypercalcemic) occurred in 35/43 (81.4%) children and 41/46 (89.1%) adults at any time point. Resolution of secondary hyperparathyroidism was observed in all children, except two with parathyroidectomies at ages 15 and 18 for tertiary hyperparathyroidism. Resolution of secondary hyperparathyroidism was observed in 27/41 adults. Tertiary (or hypercalcemic) hyperparathyroidism had an overall prevalence of 14/84 (16.67%) patients or 14/46 (30.4%) of adults (n=10 with PTH ≥65 pg/mL plus Calcium ≥10.5 mg/dl; n=1 with PTH ≥65 pg/mL plus Calcium 10.2-10.4 mg/dl; n=2 with PTH ≥50 pg/mL plus Calcium ≥10.5 mg/dL; n=1 with parathyroidectomy prior to presentation to our center). Parathyroidectomy was documented in 8/84 (9.5%) of the total population, or 8/46 (17.4%) of adults with XLH. After parathyroidectomy, residual or recurrent tertiary hyperparathyroidism was detected in 6/8 patients at a median of 6 years (ranging from 0 to 29 years). One patient had chronic postoperative hypoparathyroidism, and one patient remains normocalcemic 4 years after surgery. The majority of patients with XLH develop hyperparathyroidism during treatment with phosphate and active vitamin D. A significant proportion develop hypercalcemic hyperparathyroidism and most had recurrence of parathyroid autonomy after surgery. Careful monitoring and dose adjustment to minimize elevations of PTH are recommended.